Provider Demographics
NPI:1366005936
Name:CHIRICAHUA COMMUNITY HEALTH CENTERS, INC.
Entity Type:Organization
Organization Name:CHIRICAHUA COMMUNITY HEALTH CENTERS, INC.
Other - Org Name:CHIRICAHUA DOUGLAS PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:P
Authorized Official - Last Name:MELK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:520-364-1429
Mailing Address - Street 1:1205 N F AVE
Mailing Address - Street 2:
Mailing Address - City:DOUGLAS
Mailing Address - State:AZ
Mailing Address - Zip Code:85607-1920
Mailing Address - Country:US
Mailing Address - Phone:520-364-6852
Mailing Address - Fax:520-364-4261
Practice Address - Street 1:1111 N F AVE
Practice Address - Street 2:
Practice Address - City:DOUGLAS
Practice Address - State:AZ
Practice Address - Zip Code:85607-1918
Practice Address - Country:US
Practice Address - Phone:520-364-6860
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-04-18
Last Update Date:2021-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ527724Medicaid