Provider Demographics
NPI:1669501540
Name:FORT DEFIANCE INDIAN HOSP PHARMACY
Entity Type:Organization
Organization Name:FORT DEFIANCE INDIAN HOSP PHARMACY
Other - Org Name:FORT DEFIANCE INDIAN HOSP PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:IHS PHARMACY CONSULTANT
Authorized Official - Prefix:
Authorized Official - First Name:PAMELA
Authorized Official - Middle Name:
Authorized Official - Last Name:SCHWEITZER
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:602-364-5277
Mailing Address - Street 1:PO BOX 31001-0654
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91110-0654
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:INTERSECTION OF HWY 12 AND HWY 7
Practice Address - Street 2:
Practice Address - City:FORT DEFIANCE
Practice Address - State:AZ
Practice Address - Zip Code:86504
Practice Address - Country:US
Practice Address - Phone:928-729-8328
Practice Address - Fax:928-729-8348
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-05
Last Update Date:2010-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332800000XSuppliersIndian Health Service/Tribal/Urban Indian Health (I/T/U) Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
0324424OtherNCPDP PROVIDER IDENTIFICATION NUMBER
AZ66645Medicaid