Provider Demographics
NPI:1487855045
Name:RIVERSIDE-SAN BERNARDINO COUNTY INDIAN HEALTH, INC.
Entity Type:Organization
Organization Name:RIVERSIDE-SAN BERNARDINO COUNTY INDIAN HEALTH, INC.
Other - Org Name:SOBOBA INDIAN CLINIC PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF PHARMACY
Authorized Official - Prefix:
Authorized Official - First Name:JEEVAN
Authorized Official - Middle Name:
Authorized Official - Last Name:DHOUNI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:909-864-1097
Mailing Address - Street 1:11980 MOUNT VERNON AVE
Mailing Address - Street 2:
Mailing Address - City:GRAND TERRACE
Mailing Address - State:CA
Mailing Address - Zip Code:92313-5172
Mailing Address - Country:US
Mailing Address - Phone:909-864-1097
Mailing Address - Fax:951-225-6879
Practice Address - Street 1:23119 SOBOBA WAY
Practice Address - Street 2:
Practice Address - City:SAN JACINTO
Practice Address - State:CA
Practice Address - Zip Code:92583-5517
Practice Address - Country:US
Practice Address - Phone:951-654-0803
Practice Address - Fax:951-654-9387
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-30
Last Update Date:2023-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3336C0002X
CAPHY43887332800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332800000XSuppliersIndian Health Service/Tribal/Urban Indian Health (I/T/U) Pharmacy
No3336C0002XSuppliersPharmacyClinic Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2005498OtherPK
CAFHC03854FMedicaid