Provider Demographics
NPI:1548378318
Name:SQUAXIN ISLAND TRIBE
Entity Type:Organization
Organization Name:SQUAXIN ISLAND TRIBE
Other - Org Name:KAMILCHE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:HHS DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:J
Authorized Official - Last Name:FOX
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:360-427-9006
Mailing Address - Street 1:90 SE KLAH CHE MIN DRIVE
Mailing Address - Street 2:
Mailing Address - City:SHELTON
Mailing Address - State:WA
Mailing Address - Zip Code:98584
Mailing Address - Country:US
Mailing Address - Phone:360-427-9006
Mailing Address - Fax:360-427-1951
Practice Address - Street 1:90 SE KLAH CHE MIN DRIVE
Practice Address - Street 2:
Practice Address - City:SHELTON
Practice Address - State:WA
Practice Address - Zip Code:98584
Practice Address - Country:US
Practice Address - Phone:360-427-9006
Practice Address - Fax:360-427-1951
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SQUAXIN ISLAND TRIBE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-08-29
Last Update Date:2008-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
4929709OtherNABP NCPBP
4929709OtherNABP NCPBP