Basic Information
| Provider Information | |||||||||
| NPI: | 1386246221 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | LAGUNA HEALTHCARE CORPORATION | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | LAGUNA COMMUNITY HEALTH CENTER PHARMACY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 549 | ||||||||
| Address2: | |||||||||
| City: | PARAJE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 870070549 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5054310711 | ||||||||
| FaxNumber: | 5054310749 | ||||||||
| Practice Location | |||||||||
| Address1: | 6 BASSWOOD RD | ||||||||
| Address2: | |||||||||
| City: | PARAJE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 87007 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5054310750 | ||||||||
| FaxNumber: | 5054310749 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/16/2020 | ||||||||
| LastUpdateDate: | 04/16/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BECKER | ||||||||
| AuthorizedOfficialFirstName: | TISCHA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PHARMACY DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 5054310750 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | LAGUNA HEALTHCARE CORP | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | PHARMD | ||||||||
| NPICertificationDate: | 04/16/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1835P2201X | N | 193200000X MULTI-SPECIALTY GROUP | 332800000X | Y | Suppliers | Indian Health Service/Tribal/Urban Indian Health (I/T/U) Pharmacy |
ID Information
| ID | Type | State | Issuer | Description | 02239540 | 05 | NM | MEDICAID |