Provider Demographics
NPI:1336379650
Name:FORT DUCHESNE INDIAN HEALTH CENTER LABORATORY
Entity Type:Organization
Organization Name:FORT DUCHESNE INDIAN HEALTH CENTER LABORATORY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:GARY
Authorized Official - Middle Name:
Authorized Official - Last Name:MARTIN
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMACIST
Authorized Official - Phone:435-725-6874
Mailing Address - Street 1:6822 EAST 1000 SOUTH
Mailing Address - Street 2:
Mailing Address - City:FORT DUCHESNE
Mailing Address - State:UT
Mailing Address - Zip Code:84026
Mailing Address - Country:US
Mailing Address - Phone:435-725-6874
Mailing Address - Fax:435-725-6889
Practice Address - Street 1:6822 EAST 1000 SOUTH
Practice Address - Street 2:
Practice Address - City:FORT DUCHESNE
Practice Address - State:UT
Practice Address - Zip Code:84026
Practice Address - Country:US
Practice Address - Phone:435-725-6874
Practice Address - Fax:435-725-6889
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DHHS INDIAN HEALTH SERVICE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-07-21
Last Update Date:2013-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT700000000009Medicaid
UTHSZ216Medicare PIN
UTD07808Medicare UPIN