Basic Information
| Provider Information | |||||||||
| NPI: | 1235280223 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SOUTHERN INDIAN HEALTH COUNCIL INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | SOUTHERN INDIAN HEALTH COUNCIL | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 4058 WILLOWS RD | ||||||||
| Address2: | |||||||||
| City: | ALPINE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 919011668 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6194451188 | ||||||||
| FaxNumber: | 6194452892 | ||||||||
| Practice Location | |||||||||
| Address1: | 4058 WILLOWS RD | ||||||||
| Address2: | |||||||||
| City: | ALPINE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 919011668 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6194451188 | ||||||||
| FaxNumber: | 6194452892 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/16/2007 | ||||||||
| LastUpdateDate: | 10/04/2017 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | GARCIA | ||||||||
| AuthorizedOfficialFirstName: | DEAN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PIC | ||||||||
| AuthorizedOfficialTelephone: | 6194451188 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | PHARMD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 333600000X | N | Suppliers | Pharmacy | 3336C0003X | N | Suppliers | Pharmacy | Community/Retail Pharmacy | 332800000X | PHE35491 | CA | Y | Suppliers | Indian Health Service/Tribal/Urban Indian Health (I/T/U) Pharmacy |
ID Information
| ID | Type | State | Issuer | Description | PHE35491 | 05 | CA | MEDICAID | 1997735 | 01 | PK | OTHER |