Provider Demographics
NPI:1538219381
Name:EL RENO IHS PHARMACY
Entity type:Organization
Organization Name:EL RENO IHS PHARMACY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:AREA PHARMACY CONSULTANT
Authorized Official - Prefix:
Authorized Official - First Name:TRACIE
Authorized Official - Middle Name:
Authorized Official - Last Name:PATTEN
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:405-951-6035
Mailing Address - Street 1:PO BOX 676744
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75267-6744
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1801 PARKVIEW DR
Practice Address - Street 2:
Practice Address - City:EL RENO
Practice Address - State:OK
Practice Address - Zip Code:73036-2103
Practice Address - Country:US
Practice Address - Phone:405-234-8400
Practice Address - Fax:405-234-8409
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-12
Last Update Date:2017-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3336S0011X, 333600000X
OK26-6688332800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332800000XSuppliersIndian Health Service/Tribal/Urban Indian Health (I/T/U) Pharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2076216OtherPK
OK100231960LMedicaid