Provider Demographics
NPI:1053484998
Name:SUSANVILLE INDIAN RANCHERIA
Entity Type:Organization
Organization Name:SUSANVILLE INDIAN RANCHERIA
Other - Org Name:LASSEN INDIAN HEALTH CENTER PHARMACY
Other - Org Type:Other Name
Authorized Official - Title/Position:TRIBAL CHAIRMAN
Authorized Official - Prefix:MR
Authorized Official - First Name:STACY
Authorized Official - Middle Name:
Authorized Official - Last Name:DIXON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:530-257-6264
Mailing Address - Street 1:795 JOAQUIN ST
Mailing Address - Street 2:
Mailing Address - City:SUSANVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:96130-3628
Mailing Address - Country:US
Mailing Address - Phone:530-257-8581
Mailing Address - Fax:530-251-1846
Practice Address - Street 1:795 JOAQUIN ST
Practice Address - Street 2:
Practice Address - City:SUSANVILLE
Practice Address - State:CA
Practice Address - Zip Code:96130-3628
Practice Address - Country:US
Practice Address - Phone:530-257-8581
Practice Address - Fax:530-251-1846
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SUSANVILLE INDIAN RANCHERIA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-11-16
Last Update Date:2008-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPHE47046332800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332800000XSuppliersIndian Health Service/Tribal/Urban Indian Health (I/T/U) Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPHA470460Medicaid