Provider Demographics
NPI:1528402336
Name:LAKE COUNTY TRIBAL HEALTH CONSORTIUM, INC.
Entity Type:Organization
Organization Name:LAKE COUNTY TRIBAL HEALTH CONSORTIUM, INC.
Other - Org Name:LAKE COUNTY TRIBAL HEALTH PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:ERNESTO
Authorized Official - Middle Name:
Authorized Official - Last Name:PADILLA
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:707-263-8382
Mailing Address - Street 1:925 BEVINS CT
Mailing Address - Street 2:
Mailing Address - City:LAKEPORT
Mailing Address - State:CA
Mailing Address - Zip Code:95453-9754
Mailing Address - Country:US
Mailing Address - Phone:707-263-8382
Mailing Address - Fax:707-263-3790
Practice Address - Street 1:925 BEVINS CT
Practice Address - Street 2:
Practice Address - City:LAKEPORT
Practice Address - State:CA
Practice Address - Zip Code:95453-9754
Practice Address - Country:US
Practice Address - Phone:707-263-8382
Practice Address - Fax:707-263-3790
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LAKE COUNTY TRIBAL HEALTH CONSORTIUM, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-04-23
Last Update Date:2013-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA51235332800000X, 3336C0002X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332800000XSuppliersIndian Health Service/Tribal/Urban Indian Health (I/T/U) Pharmacy
No3336C0002XSuppliersPharmacyClinic Pharmacy