Provider Demographics
NPI:1174653752
Name:PINE RIDGE INDIAN HEALTH SERVICE HOSPITAL
Entity Type:Organization
Organization Name:PINE RIDGE INDIAN HEALTH SERVICE HOSPITAL
Other - Org Name:WANBLEE HEALTH CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACY PROGRAM SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:
Authorized Official - Last Name:CUMMINGS
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:405-951-6086
Mailing Address - Street 1:3120 SOLUTIONS CTR
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-3001
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:210 1ST ST
Practice Address - Street 2:
Practice Address - City:WANBLEE
Practice Address - State:SD
Practice Address - Zip Code:57577
Practice Address - Country:US
Practice Address - Phone:605-462-6155
Practice Address - Fax:605-462-6551
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PINE RIDGE INDIAN HEALTH SERVICE HOSPITAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-03-06
Last Update Date:2020-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332800000XSuppliersIndian Health Service/Tribal/Urban Indian Health (I/T/U) Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD5540040Medicaid
4304907OtherNCPDP PROVIDER IDENTIFICATION NUMBER