Organization
PONCA TRIBE OF NEBRASKA
Active
Parent organization
PONCA TRIBE OF NEBRASKA
Other names
Fred LeRoy Health and Wellness Center Pharmacy
Organization subpart
Yes
Provider details
NPI number
Legal business name
PONCA TRIBE OF NEBRASKA
Authorized official
MR. DONALD LEE MS (CHIEF EXECUTIVE OFFICER)
(402) 734-5275
Entity
Organization
Contact information
Practice address
2602 J ST, FRED LEROY HEALTH AND WELLNESS CENTER PHARMACY, OMAHA, NE 68107-1643
(402) 734-5275
(402) 733-3487
Mailing address
2602 J ST, FRED LEROY HEALTH AND WELLNESS CENTER PHARMACY, OMAHA, NE 68107-1643
(402) 734-5275
(402) 733-3487
Taxonomy
Speciality
Code
Description
License number
State
332800000X
Indian Health Service/Tribal/Urban Indian Health (I/T/U) Pharmacy
Primary
2884
NE
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
2817964
NCPDP
—
01
—
2884
PHARMACY LICENSE NUMBER
NE
Enumeration date
06/22/2011
Last updated
06/22/2011
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