Provider Demographics
NPI:1467550475
Name:PUEBLO OF SAN FELIPE
Entity Type:Organization
Organization Name:PUEBLO OF SAN FELIPE
Other - Org Name:SAN FELIPE HEALTH CLINIC PHCY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:TRIBAL ADMIN
Authorized Official - Prefix:
Authorized Official - First Name:DARYL
Authorized Official - Middle Name:
Authorized Official - Last Name:CANDELARIA
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD RPH
Authorized Official - Phone:505-867-3381
Mailing Address - Street 1:PO BOX 4342
Mailing Address - Street 2:PO BOX 4339
Mailing Address - City:SAN FELIPE
Mailing Address - State:NM
Mailing Address - Zip Code:87001
Mailing Address - Country:US
Mailing Address - Phone:505-867-9616
Mailing Address - Fax:505-771-9940
Practice Address - Street 1:3 CEDAR ST
Practice Address - Street 2:SAN FELIPE PUEBLO
Practice Address - City:SAN FELIPE
Practice Address - State:NM
Practice Address - Zip Code:87001
Practice Address - Country:US
Practice Address - Phone:505-867-5485
Practice Address - Fax:505-771-9940
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-21
Last Update Date:2018-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332800000XSuppliersIndian Health Service/Tribal/Urban Indian Health (I/T/U) Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM81271875Medicaid
2058717OtherPK