Provider Demographics
NPI:1386832087
Name:WINSLOW INDIAN HEALTH CARE CENTER, INC
Entity Type:Organization
Organization Name:WINSLOW INDIAN HEALTH CARE CENTER, INC
Other - Org Name:WINSLOW INDIAN CARE CENTER PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:SALLY
Authorized Official - Middle Name:
Authorized Official - Last Name:PETE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:928-289-6101
Mailing Address - Street 1:500 INDIANA AVE
Mailing Address - Street 2:
Mailing Address - City:WINSLOW
Mailing Address - State:AZ
Mailing Address - Zip Code:86047-2169
Mailing Address - Country:US
Mailing Address - Phone:928-289-4646
Mailing Address - Fax:928-289-6290
Practice Address - Street 1:500 INDIANA AVE
Practice Address - Street 2:
Practice Address - City:WINSLOW
Practice Address - State:AZ
Practice Address - Zip Code:86047-2169
Practice Address - Country:US
Practice Address - Phone:928-289-4646
Practice Address - Fax:928-289-6290
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-09
Last Update Date:2019-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes3336I0012XSuppliersPharmacyInstitutional PharmacyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ03-24513OtherNCPDP
AZ060020-01Medicaid