Provider Demographics
NPI:1659490225
Name:TSAILE HEALTH CENTER PHARMACY
Entity Type:Organization
Organization Name:TSAILE HEALTH CENTER PHARMACY
Other - Org Name:TSAILE HEALTH CENTER PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACY PROGRAM SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:
Authorized Official - Last Name:CUMMINGS
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:405-951-6086
Mailing Address - Street 1:PO BOX 21C
Mailing Address - Street 2:PHARMACY DEPT
Mailing Address - City:TSAILE
Mailing Address - State:AZ
Mailing Address - Zip Code:86556
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:INTERSECTION RT 64 AND 12
Practice Address - Street 2:
Practice Address - City:TSAILE
Practice Address - State:AZ
Practice Address - Zip Code:86556
Practice Address - Country:US
Practice Address - Phone:928-724-3643
Practice Address - Fax:928-724-3605
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-28
Last Update Date:2015-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332800000XSuppliersIndian Health Service/Tribal/Urban Indian Health (I/T/U) Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ61119Medicaid
AZ061119Medicaid
1991278OtherPK