Provider Demographics
NPI:1538219431
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:CHIEF OF PHARMACY
Authorized Official - Prefix:
Authorized Official - First Name:BRETT
Authorized Official - Middle Name:JOSEPH
Authorized Official - Last Name:WHITEHEAD
Authorized Official - Suffix:
Authorized Official - Credentials:PHARM D
Authorized Official - Phone:405-234-8422
Mailing Address - Street 1:1801 PARKVIEW DRIVE
Mailing Address - Street 2:
Mailing Address - City:EL RENO
Mailing Address - State:OK
Mailing Address - Zip Code:73036
Mailing Address - Country:US
Mailing Address - Phone:405-234-8422
Mailing Address - Fax:405-234-8409
Practice Address - Street 1:1801 PARKVIEW DRIVE
Practice Address - Street 2:
Practice Address - City:EL RENO
Practice Address - State:OK
Practice Address - Zip Code:73632
Practice Address - Country:US
Practice Address - Phone:405-234-8244
Practice Address - Fax:405-234-8409
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-11
Last Update Date:2017-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK281620332800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332800000XSuppliersIndian Health Service/Tribal/Urban Indian Health (I/T/U) Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100231960AMedicaid
3721354OtherNCPDP PROVIDER IDENTIFICATION NUMBER