Provider Demographics
NPI:1659406171
Name:PUYALLUP TRIBAL HEALTH AUTHORITY
Entity Type:Organization
Organization Name:PUYALLUP TRIBAL HEALTH AUTHORITY
Other - Org Name:PUYALLUP TRIBAL HEALTH AUTHORITY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:CHRIS
Authorized Official - Middle Name:
Authorized Official - Last Name:HENRY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:253-593-0232
Mailing Address - Street 1:2209 E 32ND ST
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98404-4922
Mailing Address - Country:US
Mailing Address - Phone:253-593-0232
Mailing Address - Fax:253-382-2091
Practice Address - Street 1:2209 E 32ND ST
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98404
Practice Address - Country:US
Practice Address - Phone:253-593-0232
Practice Address - Fax:253-382-2091
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-23
Last Update Date:2018-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA332800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332800000XSuppliersIndian Health Service/Tribal/Urban Indian Health (I/T/U) Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA4925357OtherNCPD
WA17462OtherLABOR & INDUSTRIES
WA6021372Medicaid