Provider Demographics
NPI:1891822003
Name:CONFEDERATED TRIBES OF SILETZ
Entity Type:Organization
Organization Name:CONFEDERATED TRIBES OF SILETZ
Other - Org Name:SILETZ COMMUNITY HEALTH CLINIC PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:HEALTH DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MIRANDA
Authorized Official - Middle Name:
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:541-444-1030
Mailing Address - Street 1:PO BOX 320
Mailing Address - Street 2:
Mailing Address - City:SILETZ
Mailing Address - State:OR
Mailing Address - Zip Code:97380-0320
Mailing Address - Country:US
Mailing Address - Phone:541-444-1030
Mailing Address - Fax:
Practice Address - Street 1:200 GWEE-SHUT ROAD
Practice Address - Street 2:
Practice Address - City:SILETZ
Practice Address - State:OR
Practice Address - Zip Code:97380
Practice Address - Country:US
Practice Address - Phone:541-444-1030
Practice Address - Fax:541-444-9695
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-27
Last Update Date:2022-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORRP-0002621-CS332800000X, 332B00000X, 3336C0002X, 3336M0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332800000XSuppliersIndian Health Service/Tribal/Urban Indian Health (I/T/U) Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No3336C0002XSuppliersPharmacyClinic Pharmacy
No3336M0002XSuppliersPharmacyMail Order Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR051966Medicaid
OR0924730001Medicare NSC
ORR0000WCKJVMedicare UPIN