Provider Demographics
NPI:1144077470
Name:UPPER MATTAPONI INDIAN TRIBE
Entity type:Organization
Organization Name:UPPER MATTAPONI INDIAN TRIBE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:
Authorized Official - Last Name:TUPPONCE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:804-238-9922
Mailing Address - Street 1:27 COMMERCE LN
Mailing Address - Street 2:
Mailing Address - City:KING WILLIAM
Mailing Address - State:VA
Mailing Address - Zip Code:23086
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:27 COMMERCE LN
Practice Address - Street 2:
Practice Address - City:KING WILLIAM
Practice Address - State:VA
Practice Address - Zip Code:23086
Practice Address - Country:US
Practice Address - Phone:804-769-2015
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:UPPER MATTAPONI INDIAN TRIBE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2024-05-03
Last Update Date:2025-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332800000XSuppliersIndian Health Service/Tribal/Urban Indian Health (I/T/U) Pharmacy
No3336C0002XSuppliersPharmacyClinic Pharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA30015299710005Medicaid
VA3001529971001Medicaid