Provider Demographics
NPI:1508887993
Name:DHEW IND HLTH SV HLTH SVS&MNTAL HLTH ADM
Entity Type:Organization
Organization Name:DHEW IND HLTH SV HLTH SVS&MNTAL HLTH ADM
Other - Org Name:FORT DUCHESNE PHS INDIAN HEALTH CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF PHARMACIST
Authorized Official - Prefix:MR
Authorized Official - First Name:DELBERT
Authorized Official - Middle Name:GARY
Authorized Official - Last Name:MARTIN
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:435-725-6874
Mailing Address - Street 1:6822 EAST 1000 SOUTH
Mailing Address - Street 2:FORT DUCHESNE PHS INDIAN HEALTH CENTER
Mailing Address - City:FORT DUCHESNE
Mailing Address - State:UT
Mailing Address - Zip Code:84026
Mailing Address - Country:US
Mailing Address - Phone:435-722-5122
Mailing Address - Fax:435-722-9137
Practice Address - Street 1:6822 EAST 1000 SOUTH
Practice Address - Street 2:FORT DUCHESNE PHS INDIAN HEALTH CENTER
Practice Address - City:FORT DUCHESNE
Practice Address - State:UT
Practice Address - Zip Code:84026
Practice Address - Country:US
Practice Address - Phone:435-722-5122
Practice Address - Fax:435-722-9137
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-21
Last Update Date:2013-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP0904XAmbulatory Health Care FacilitiesClinic/CenterPublic Health, Federal
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT700000000009Medicaid
AZAZ0522260OtherBLUE CROSS
UTHSZ216Medicare PIN
UT700000000009Medicaid