Basic Information
| Provider Information | |||||||||
| NPI: | 1548307929 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | YAKAMA INDIAN HEALTH CENTER | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | DHHS IHS YAKAMA SERVICE UNIT | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 401 BUSTER RD | ||||||||
| Address2: | |||||||||
| City: | TOPPENISH | ||||||||
| State: | WA | ||||||||
| PostalCode: | 989489792 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5098652102 | ||||||||
| FaxNumber: | 5098654986 | ||||||||
| Practice Location | |||||||||
| Address1: | 401 BUSTER RD | ||||||||
| Address2: | |||||||||
| City: | TOPPENISH | ||||||||
| State: | WA | ||||||||
| PostalCode: | 989489792 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5098652102 | ||||||||
| FaxNumber: | 5098654986 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/01/2007 | ||||||||
| LastUpdateDate: | 04/29/2019 | ||||||||
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| AuthorizedOfficialLastName: | SAMPSON | ||||||||
| AuthorizedOfficialFirstName: | JAY | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 5098652102 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | YAKAMA INDIAN HEALTH CENTER | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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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 | 7100506 | 05 | WA | MEDICAID | AW3308574 | 01 | WA | DEA ORG. NO. | OTHER | 21940 | 01 | WA | LAB.&INDSTRY.MED# | OTHER | 4926311 | 01 | WA | NATL.ASSOC.BD.PHARM. | OTHER | 51239 | 01 | WA | LABOR & INDUSTRY RX | OTHER |