Provider Demographics
NPI:1144382219
Name:PHOENIX INDIAN MEDICAL CENTER
Entity Type:Organization
Organization Name:PHOENIX INDIAN MEDICAL CENTER
Other - Org Name:INDIAN PUBLIC HEALTH SERVICES
Other - Org Type:Other Name
Authorized Official - Title/Position:PHARMACIST
Authorized Official - Prefix:MS
Authorized Official - First Name:VELLIYAH
Authorized Official - Middle Name:ELLEN
Authorized Official - Last Name:CRAIG
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:602-263-1200
Mailing Address - Street 1:6414 S 26TH AVE
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85041-5365
Mailing Address - Country:US
Mailing Address - Phone:602-296-4750
Mailing Address - Fax:
Practice Address - Street 1:4212 N 16TH ST
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85016-5319
Practice Address - Country:US
Practice Address - Phone:602-296-4750
Practice Address - Fax:602-263-1621
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-15
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMRP00005927251K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251K00000XAgenciesPublic Health or Welfare