Provider Demographics
NPI:1568461267
Name:SONOMA COUNTY INDIAN HEALTH PROJECT, INC
Entity Type:Organization
Organization Name:SONOMA COUNTY INDIAN HEALTH PROJECT, INC
Other - Org Name:SONOMA COUNTY INDIAN HEALTH PROJECT PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:INTERIM CEO
Authorized Official - Prefix:
Authorized Official - First Name:BETTY
Authorized Official - Middle Name:
Authorized Official - Last Name:ARTERBERRY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:707-521-4660
Mailing Address - Street 1:144 STONY POINT RD
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95401-4122
Mailing Address - Country:US
Mailing Address - Phone:707-521-4585
Mailing Address - Fax:707-521-4599
Practice Address - Street 1:144 STONY POINT RD
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95401-4122
Practice Address - Country:US
Practice Address - Phone:707-521-4585
Practice Address - Fax:707-521-4599
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SONOMA COUNT INDIAN HEALTH PROJECT, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2005-07-15
Last Update Date:2023-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPHY45307333600000X
3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA0557910OtherNCPDP #
CAPHA45307Medicaid
CAPHA45307Medicaid
CA051867Medicare ID - Type Unspecified
CA0557910OtherNCPDP #