Basic Information
| Provider Information | |||||||||
| NPI: | 1114430147 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | GILA RIVER HEALTH CARE CORPORATION | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | RED TAIL HAWK HEALTH CENTER PHARMACY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | P.O. BOX 38 | ||||||||
| Address2: | |||||||||
| City: | SACATON | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 85147 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6025281200 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3042 W. QUEEN CREEK ROAD | ||||||||
| Address2: | |||||||||
| City: | CHANDLER | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 85286 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6025281200 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/13/2017 | ||||||||
| LastUpdateDate: | 11/13/2017 | ||||||||
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| AuthorizedOfficialLastName: | GEMBERLING | ||||||||
| AuthorizedOfficialFirstName: | SCOTT | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 6025281427 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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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 | 334582 | 05 | AZ | MEDICAID |