Provider Demographics
NPI:1558882233
Name:CHIRICAHUA COMMUNITY HEALTH CENTERS INC
Entity Type:Organization
Organization Name:CHIRICAHUA COMMUNITY HEALTH CENTERS INC
Other - Org Name:CHIRICAHUA PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:P
Authorized Official - Last Name:MELK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:520-364-6852
Mailing Address - Street 1:1205 N F AVE
Mailing Address - Street 2:
Mailing Address - City:DOUGLAS
Mailing Address - State:AZ
Mailing Address - Zip Code:85607-1920
Mailing Address - Country:US
Mailing Address - Phone:520-364-1429
Mailing Address - Fax:250-364-4261
Practice Address - Street 1:155 CALLE PORTAL STE 600
Practice Address - Street 2:
Practice Address - City:SIERRA VISTA
Practice Address - State:AZ
Practice Address - Zip Code:85635-2973
Practice Address - Country:US
Practice Address - Phone:520-515-8678
Practice Address - Fax:520-459-8423
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-07-03
Last Update Date:2021-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
AZY0073213336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ296387Medicaid
AZ296387Medicaid