Basic Information
| Provider Information | |||||||||
| NPI: | 1497791859 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CHEROKEE NATION | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | WILMA P MANKILLER HEALTH CENTER RX | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | CHEROKEE NATION | ||||||||
| Address2: | DEPT 2269 | ||||||||
| City: | TULSA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 741820001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9184535000 | ||||||||
| FaxNumber: | 9184586222 | ||||||||
| Practice Location | |||||||||
| Address1: | 471688 HIGHWAY 51 | ||||||||
| Address2: | |||||||||
| City: | STILWELL | ||||||||
| State: | OK | ||||||||
| PostalCode: | 749604490 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9186968800 | ||||||||
| FaxNumber: | 9186968840 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/22/2006 | ||||||||
| LastUpdateDate: | 08/24/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | CHIOVOLONI | ||||||||
| AuthorizedOfficialFirstName: | IVANNE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PHARMACIST | ||||||||
| AuthorizedOfficialTelephone: | 9182073987 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 08/24/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332B00000X | N | Suppliers | Durable Medical Equipment & Medical Supplies | 333600000X | N | Suppliers | Pharmacy | 3336S0011X | N | Suppliers | Pharmacy | Specialty Pharmacy | 332800000X | 46-3911 | OK | Y | Suppliers | Indian Health Service/Tribal/Urban Indian Health (I/T/U) Pharmacy |
ID Information
| ID | Type | State | Issuer | Description | 100236190G | 05 | OK | MEDICAID | 2074919 | 01 | PK | OTHER |