Provider Demographics
NPI:1760728380
Name:PECHANGA INDIAN HEALTH CLINIC PHARMACY
Entity Type:Organization
Organization Name:PECHANGA INDIAN HEALTH CLINIC PHARMACY
Other - Org Name:PECHANGA INDIAN HEALTH CLINIC PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:
Authorized Official - Last Name:THOMSEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:909-864-1097
Mailing Address - Street 1:12784 PECHANGA RD
Mailing Address - Street 2:
Mailing Address - City:TEMECULA
Mailing Address - State:CA
Mailing Address - Zip Code:92592
Mailing Address - Country:US
Mailing Address - Phone:951-676-6810
Mailing Address - Fax:951-676-6421
Practice Address - Street 1:47001 PALA RD
Practice Address - Street 2:
Practice Address - City:TEMECULA
Practice Address - State:CA
Practice Address - Zip Code:92592-2925
Practice Address - Country:US
Practice Address - Phone:951-676-6810
Practice Address - Fax:951-676-6421
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-12-31
Last Update Date:2021-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA50823332800000X
333600000X, 3336C0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332800000XSuppliersIndian Health Service/Tribal/Urban Indian Health (I/T/U) Pharmacy
No333600000XSuppliersPharmacy
No3336C0002XSuppliersPharmacyClinic Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
5646178OtherNCPDP PROVIDER IDENTIFICATION NUMBER