Basic Information
| Provider Information | |||||||||
| NPI: | 1629525605 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CANONCITO BAND OF NAVAJOS HEALTH CENTER, INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | CANONCITO BAND OF NAVAJOS HEALTH CENTER, INC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 129 MEDICINE HORSE RD | ||||||||
| Address2: | |||||||||
| City: | CANONCITO | ||||||||
| State: | NM | ||||||||
| PostalCode: | 87026 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5059082307 | ||||||||
| FaxNumber: | 5059082310 | ||||||||
| Practice Location | |||||||||
| Address1: | 129 MEDICINE HORSE ROAD | ||||||||
| Address2: | |||||||||
| City: | CANONCITO | ||||||||
| State: | NM | ||||||||
| PostalCode: | 87026 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5059082307 | ||||||||
| FaxNumber: | 5059082310 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/07/2016 | ||||||||
| LastUpdateDate: | 02/21/2017 | ||||||||
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| AuthorizedOfficialLastName: | VARGA | ||||||||
| AuthorizedOfficialFirstName: | ALEXANDER | ||||||||
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| AuthorizedOfficialTitleorPosition: | LCDR/ CHIEF PHARMACIST | ||||||||
| AuthorizedOfficialTelephone: | 5059082307 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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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 | 1205092160 | 05 | NM | MEDICAID | 2166309 | 01 | PK | OTHER | 1124119698 | 05 | NM | MEDICAID | 1962591669 | 05 | NM | MEDICAID | 1295726073 | 05 | NM | MEDICAID | 1619061090 | 05 | TX | MEDICAID |