Basic Information
| Provider Information | |||||||||
| NPI: | 1174653752 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PINE RIDGE INDIAN HEALTH SERVICE HOSPITAL | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | WANBLEE HEALTH CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3120 SOLUTIONS CTR | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606773001 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 210 1ST ST | ||||||||
| Address2: | |||||||||
| City: | WANBLEE | ||||||||
| State: | SD | ||||||||
| PostalCode: | 57577 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6054626155 | ||||||||
| FaxNumber: | 6054626551 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/06/2007 | ||||||||
| LastUpdateDate: | 11/25/2020 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | CUMMINGS | ||||||||
| AuthorizedOfficialFirstName: | JAMES | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PHARMACY PROGRAM SPECIALIST | ||||||||
| AuthorizedOfficialTelephone: | 4059516086 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | PINE RIDGE INDIAN HEALTH SERVICE HOSPITAL | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | PHARMD | ||||||||
| NPICertificationDate: | 11/24/2020 | ||||||||
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 | 5540040 | 05 | SD | MEDICAID | 4304907 | 01 | NCPDP PROVIDER IDENTIFICATION NUMBER | OTHER |