Provider Demographics
NPI:1154837383
Name:CONFEDERATED TRIBES OF SILETZ
Entity Type:Organization
Organization Name:CONFEDERATED TRIBES OF SILETZ
Other - Org Name:SILETZ COMMUNITY HEALTH CLINIC PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:HEALTH DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MIRANDA
Authorized Official - Middle Name:
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:541-444-1030
Mailing Address - Street 1:PO BOX 320
Mailing Address - Street 2:
Mailing Address - City:SILETZ
Mailing Address - State:OR
Mailing Address - Zip Code:97380-0320
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:200 GWEE SHUT RD
Practice Address - Street 2:
Practice Address - City:SILETZ
Practice Address - State:OR
Practice Address - Zip Code:97380-2036
Practice Address - Country:US
Practice Address - Phone:541-444-1030
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-12-26
Last Update Date:2022-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORRP-0002621-CS3336C0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0002XSuppliersPharmacyClinic Pharmacy