Provider Demographics
NPI:1326080425
Name:TON SANTA ROSA HEALTH CENTER
Entity Type:Organization
Organization Name:TON SANTA ROSA HEALTH CENTER
Other - Org Name:TON SANTA ROSA HEALTH CENTER PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DEPUTY CEO
Authorized Official - Prefix:
Authorized Official - First Name:DIANE
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:SHANLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:520-383-7285
Mailing Address - Street 1:PO BOX 31001-0663
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91110-0663
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:HC01 HIGHWAY 15
Practice Address - Street 2:
Practice Address - City:SELLS
Practice Address - State:AZ
Practice Address - Zip Code:85634
Practice Address - Country:US
Practice Address - Phone:520-383-5570
Practice Address - Fax:520-383-5572
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-12
Last Update Date:2018-02-13
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
AZ02057901Medicaid
1991503OtherPK