Provider Demographics
NPI:1164553053
Name:SYCUAN TRIBAL GOVERNMENT
Entity Type:Organization
Organization Name:SYCUAN TRIBAL GOVERNMENT
Other - Org Name:SYCUAN MEDICAL DENTAL PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CONTROLLER AND CEO
Authorized Official - Prefix:
Authorized Official - First Name:SAL
Authorized Official - Middle Name:
Authorized Official - Last Name:FALCO
Authorized Official - Suffix:
Authorized Official - Credentials:BS
Authorized Official - Phone:619-445-0707
Mailing Address - Street 1:5442 DEHESA RD
Mailing Address - Street 2:
Mailing Address - City:EL CAJON
Mailing Address - State:CA
Mailing Address - Zip Code:92019-1816
Mailing Address - Country:US
Mailing Address - Phone:619-445-3518
Mailing Address - Fax:619-445-5814
Practice Address - Street 1:5442 DEHESA RD
Practice Address - Street 2:
Practice Address - City:EL CAJON
Practice Address - State:CA
Practice Address - Zip Code:92019-1816
Practice Address - Country:US
Practice Address - Phone:619-445-3518
Practice Address - Fax:619-445-5814
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-09
Last Update Date:2017-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332800000X, 333600000X
CAPHE398733336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332800000XSuppliersIndian Health Service/Tribal/Urban Indian Health (I/T/U) Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2094469OtherPK