Basic Information
Provider Information | |||||||||
NPI: | 1649374943 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | CHEROKEE INDIAN HOSPITAL AUTHORITY | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | CIHA PHARMACY | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1 HOSPITAL ROAD | ||||||||
Address2: | CALLER BOX C-268 | ||||||||
City: | CHEROKEE | ||||||||
State: | NC | ||||||||
PostalCode: | 287199253 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8284979163 | ||||||||
FaxNumber: | 8284971723 | ||||||||
Practice Location | |||||||||
Address1: | 1 HOSPITAL ROAD | ||||||||
Address2: | CALLER BOX C-268 | ||||||||
City: | CHEROKEE | ||||||||
State: | NC | ||||||||
PostalCode: | 287199253 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8284979163 | ||||||||
FaxNumber: | 8284971723 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/08/2006 | ||||||||
LastUpdateDate: | 01/03/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | DANDO | ||||||||
AuthorizedOfficialFirstName: | JONATHAN | ||||||||
AuthorizedOfficialMiddleName: | CERI | ||||||||
AuthorizedOfficialTitleorPosition: | BUSINESS OFFICE MANAGER | ||||||||
AuthorizedOfficialTelephone: | 8284979163 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | CHEROKEE INDIAN HOSPITAL AUTHORITY | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
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 | 0865592 | 05 | NC |   | MEDICAID | 3440120 | 01 | NC | NC PDP | OTHER | 5572570001 | 01 | NC | RX DME | OTHER | AU-4418768 | 01 |   | DEA # | OTHER |