Provider Demographics
NPI:1629525605
Name:CANONCITO BAND OF NAVAJOS HEALTH CENTER, INC
Entity Type:Organization
Organization Name:CANONCITO BAND OF NAVAJOS HEALTH CENTER, INC
Other - Org Name:CANONCITO BAND OF NAVAJOS HEALTH CENTER, INC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:LCDR/ CHIEF PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:ALEXANDER
Authorized Official - Middle Name:
Authorized Official - Last Name:VARGA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:505-908-2307
Mailing Address - Street 1:129 MEDICINE HORSE RD
Mailing Address - Street 2:
Mailing Address - City:CANONCITO
Mailing Address - State:NM
Mailing Address - Zip Code:87026
Mailing Address - Country:US
Mailing Address - Phone:505-908-2307
Mailing Address - Fax:505-908-2310
Practice Address - Street 1:129 MEDICINE HORSE ROAD
Practice Address - Street 2:
Practice Address - City:CANONCITO
Practice Address - State:NM
Practice Address - Zip Code:87026
Practice Address - Country:US
Practice Address - Phone:505-908-2307
Practice Address - Fax:505-908-2310
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-09-07
Last Update Date:2017-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes332800000XSuppliersIndian Health Service/Tribal/Urban Indian Health (I/T/U) PharmacyGroup - Multi-Specialty
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM1205092160Medicaid
2166309OtherPK
NM1124119698Medicaid
NM1962591669Medicaid
NM1295726073Medicaid
TX1619061090Medicaid