Provider Demographics
NPI:1235410309
Name:TUBA CITY REGIONAL HEALTH CARE CORPORATION
Entity Type:Organization
Organization Name:TUBA CITY REGIONAL HEALTH CARE CORPORATION
Other - Org Name:SACRED PEAKS HEALTH CENTER PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:LYNETTE
Authorized Official - Middle Name:
Authorized Official - Last Name:BONAR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:928-283-2944
Mailing Address - Street 1:6300 N HIGHWAY 89
Mailing Address - Street 2:
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86004
Mailing Address - Country:US
Mailing Address - Phone:928-863-7331
Mailing Address - Fax:928-526-5900
Practice Address - Street 1:6300 N HIGHWAY 89
Practice Address - Street 2:
Practice Address - City:FLAGSTAFF
Practice Address - State:AZ
Practice Address - Zip Code:86004
Practice Address - Country:US
Practice Address - Phone:928-863-7331
Practice Address - Fax:928-526-5900
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:TUBA CITY REGIONAL HEALTH CARE CORPORATION
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-09-02
Last Update Date:2019-09-10
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
0357257OtherNCPDP PROVIDER IDENTIFICATION NUMBER
AZ721250Medicaid