Basic Information
| Provider Information | |||||||||
| NPI: | 1669501540 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | FORT DEFIANCE INDIAN HOSP PHARMACY | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | FORT DEFIANCE INDIAN HOSP PHARMACY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 31001-0654 | ||||||||
| Address2: | |||||||||
| City: | PASADENA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 911100654 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | INTERSECTION OF HWY 12 AND HWY 7 | ||||||||
| Address2: | |||||||||
| City: | FORT DEFIANCE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 86504 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9287298328 | ||||||||
| FaxNumber: | 9287298348 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/05/2007 | ||||||||
| LastUpdateDate: | 01/29/2010 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | SCHWEITZER | ||||||||
| AuthorizedOfficialFirstName: | PAMELA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | IHS PHARMACY CONSULTANT | ||||||||
| AuthorizedOfficialTelephone: | 6023645277 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | PHARMD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 333600000X | N | Suppliers | Pharmacy | 332800000X | Y | Suppliers | Indian Health Service/Tribal/Urban Indian Health (I/T/U) Pharmacy |
ID Information
| ID | Type | State | Issuer | Description | 0324424 | 01 | NCPDP PROVIDER IDENTIFICATION NUMBER | OTHER | 66645 | 05 | AZ | MEDICAID |