Basic Information
| Provider Information | |||||||||
| NPI: | 1558882233 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CHIRICAHUA COMMUNITY HEALTH CENTERS INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | CHIRICAHUA PHARMACY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 1205 N F AVE | ||||||||
| Address2: | |||||||||
| City: | DOUGLAS | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 856071920 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5203641429 | ||||||||
| FaxNumber: | 2503644261 | ||||||||
| Practice Location | |||||||||
| Address1: | 155 CALLE PORTAL STE 600 | ||||||||
| Address2: | |||||||||
| City: | SIERRA VISTA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 856352973 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5205158678 | ||||||||
| FaxNumber: | 5204598423 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/03/2017 | ||||||||
| LastUpdateDate: | 09/01/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MELK | ||||||||
| AuthorizedOfficialFirstName: | JONATHAN | ||||||||
| AuthorizedOfficialMiddleName: | P | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 5203646852 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 09/01/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3336C0003X | Y007321 | AZ | N | Suppliers | Pharmacy | Community/Retail Pharmacy | 333600000X | Y | Suppliers | Pharmacy |
ID Information
| ID | Type | State | Issuer | Description | 296387 | 05 | AZ | MEDICAID |