Basic Information
| Provider Information | |||||||||
| NPI: | 1710995279 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MAKAH TRIBE | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | SOPHIE TRETTEVICK INDIA HEALTH CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 410 | ||||||||
| Address2: | |||||||||
| City: | NEAH BAY | ||||||||
| State: | WA | ||||||||
| PostalCode: | 983570410 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3606452233 | ||||||||
| FaxNumber: | 3606452305 | ||||||||
| Practice Location | |||||||||
| Address1: | 250 FORT STREET | ||||||||
| Address2: | |||||||||
| City: | NEAH BAY | ||||||||
| State: | WA | ||||||||
| PostalCode: | 98357 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3606452233 | ||||||||
| FaxNumber: | 3606452233 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/03/2006 | ||||||||
| LastUpdateDate: | 06/07/2019 | ||||||||
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| AuthorizedOfficialLastName: | TYLER | ||||||||
| AuthorizedOfficialFirstName: | KAREN | ||||||||
| AuthorizedOfficialMiddleName: | R | ||||||||
| AuthorizedOfficialTitleorPosition: | BUSINESS OFFICE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 3606452628 | ||||||||
| IsSoleProprietor: | |||||||||
| 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 | 7100209 | 05 | WA | MEDICAID |