Basic Information
Provider Information | |||||||||
NPI: | 1073671194 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | PINE HILL HEALTH CENTER | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | PINE HILL HEALTH CENTER | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PHARMACY DEPT | ||||||||
Address2: | PO BOX 310 | ||||||||
City: | PINE HILL | ||||||||
State: | NM | ||||||||
PostalCode: | 87357 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5057753271 | ||||||||
FaxNumber: | 5057753633 | ||||||||
Practice Location | |||||||||
Address1: | BIA RT 125 | ||||||||
Address2: |   | ||||||||
City: | PINE HILL | ||||||||
State: | NM | ||||||||
PostalCode: | 87357 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5057753271 | ||||||||
FaxNumber: | 5057753633 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/04/2006 | ||||||||
LastUpdateDate: | 09/14/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | BECKER | ||||||||
AuthorizedOfficialFirstName: | WILLIAM | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CLINIC ADMINISTRATOR | ||||||||
AuthorizedOfficialTelephone: | 5057753271 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | PHARMD | ||||||||
NPICertificationDate: | 09/14/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332800000X |   |   | Y |   | Suppliers | Indian Health Service/Tribal/Urban Indian Health (I/T/U) Pharmacy |   |
ID Information
ID | Type | State | Issuer | Description | 55587 | 05 | NM |   | MEDICAID | 69964 | 05 | NM |   | MEDICAID | 2058706 | 01 |   | PK | OTHER |