Provider Demographics
NPI:1255460127
Name:CHINLE HEALTH CARE PHARMACY
Entity type:Organization
Organization Name:CHINLE HEALTH CARE PHARMACY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF PHARMACY
Authorized Official - Prefix:
Authorized Official - First Name:NIVEDITA
Authorized Official - Middle Name:
Authorized Official - Last Name:DAS
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:928-674-7414
Mailing Address - Street 1:PO BOX 31001-0651
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91110-0651
Mailing Address - Country:US
Mailing Address - Phone:928-674-7042
Mailing Address - Fax:928-674-7463
Practice Address - Street 1:OFF HWY 191 HOSPITAL ROAD
Practice Address - Street 2:
Practice Address - City:CHINLE
Practice Address - State:AZ
Practice Address - Zip Code:86503
Practice Address - Country:US
Practice Address - Phone:928-674-7042
Practice Address - Fax:928-674-7463
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-05
Last Update Date:2024-07-24
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
AZ21171Medicaid
0322507OtherNCPDP PROVIDER IDENTIFICATION NUMBER
AZ021171Medicaid