Provider Demographics
NPI:1821030446
Name:INDIAN HEALTH COUNCIL PHARMACY
Entity Type:Organization
Organization Name:INDIAN HEALTH COUNCIL PHARMACY
Other - Org Name:INDIAN HEALTH COUNCIL PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACY DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:SCHOSTAG
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:760-749-1410
Mailing Address - Street 1:PO BOX 406
Mailing Address - Street 2:
Mailing Address - City:PAUMA VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92061-0406
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:50100 GOLSH RD
Practice Address - Street 2:
Practice Address - City:VALLEY CENTER
Practice Address - State:CA
Practice Address - Zip Code:92082
Practice Address - Country:US
Practice Address - Phone:760-749-1410
Practice Address - Fax:760-749-0225
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-11
Last Update Date:2015-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPHE30519332800000X
333600000X, 3336C0002X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332800000XSuppliersIndian Health Service/Tribal/Urban Indian Health (I/T/U) Pharmacy
No333600000XSuppliersPharmacy
No3336C0002XSuppliersPharmacyClinic Pharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
1997745OtherPK
CAPHA305190Medicaid