Basic Information
| Provider Information | |||||||||
| NPI: | 1225609159 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DEBO | ||||||||
| FirstName: | CHARLES | ||||||||
| MiddleName: | |||||||||
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| Credential: | PHARMD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PHS INDIAN HOSPITAL | ||||||||
| Address2: | 607 INDIAN HEALTH ROAD | ||||||||
| City: | PINE RIDGE | ||||||||
| State: | SD | ||||||||
| PostalCode: | 57770 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | PHS INDIAN HOSPITAL | ||||||||
| Address2: | 607 INDIAN HEALTH ROAD | ||||||||
| City: | PINE RIDGE | ||||||||
| State: | SD | ||||||||
| PostalCode: | 57770 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6058673192 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/01/2021 | ||||||||
| LastUpdateDate: | 07/01/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 06/09/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 183500000X | PHA.0023068 | CO | Y | Pharmacy Service Providers | Pharmacist |
No ID Information.