Basic Information
| Provider Information | |||||||||
| NPI: | 1427180009 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SANDIA HEALTH CLINIC PHARMACY | ||||||||
| LastName: | |||||||||
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| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | SANDIA HEALTH CLINIC PHARMACY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 31001-0673 | ||||||||
| Address2: | |||||||||
| City: | PASADENA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 911100675 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 481 SANDIA LOOP | ||||||||
| Address2: | |||||||||
| City: | BERNALILLO | ||||||||
| State: | NM | ||||||||
| PostalCode: | 870047076 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5058674487 | ||||||||
| FaxNumber: | 5057715126 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/10/2007 | ||||||||
| LastUpdateDate: | 12/16/2009 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | SCHWEITZER | ||||||||
| AuthorizedOfficialFirstName: | PAMELA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | IHS PHARMACY CONSULTANT | ||||||||
| AuthorizedOfficialTelephone: | 6023645277 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | PHARMD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3336C0002X | N | Suppliers | Pharmacy | Clinic Pharmacy | 332800000X | Y | Suppliers | Indian Health Service/Tribal/Urban Indian Health (I/T/U) Pharmacy |
ID Information
| ID | Type | State | Issuer | Description | 10462 | 05 | NM | MEDICAID | 3209295 | 01 | NCPDP PROVIDER IDENTIFICATION NUMBER | OTHER | H7890 | 05 | NM | MEDICAID |