Provider Demographics
NPI:1407252588
Name:IHC SANTA YSABEL PHARMACY
Entity Type:Organization
Organization Name:IHC SANTA YSABEL PHARMACY
Other - Org Name:IHC SANTA YSABEL PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACY DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:SCHOSTAG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:760-749-1410
Mailing Address - Street 1:PO BOX 10
Mailing Address - Street 2:
Mailing Address - City:SANTA YSABEL
Mailing Address - State:CA
Mailing Address - Zip Code:92070-0010
Mailing Address - Country:US
Mailing Address - Phone:760-233-5587
Mailing Address - Fax:760-765-3769
Practice Address - Street 1:110 1/2 SCHOOL HOUSE CANYON ROAD
Practice Address - Street 2:
Practice Address - City:SANTA YSABEL
Practice Address - State:CA
Practice Address - Zip Code:92070
Practice Address - Country:US
Practice Address - Phone:760-233-5587
Practice Address - Fax:760-765-3769
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-11-17
Last Update Date:2014-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPHY46552332800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332800000XSuppliersIndian Health Service/Tribal/Urban Indian Health (I/T/U) Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2148638OtherPK