Healthcare Provider Details

I. General information

NPI: 1699983361
Provider Name (Legal Business Name): KETCHIKAN INDIAN CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/18/2007
Last Update Date: 03/07/2023
Certification Date: 04/28/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2960 TONGASS AVE
KETCHIKAN AK
99901-5742
US

IV. Provider business mailing address

2960 TONGASS AVE
KETCHIKAN AK
99901-5742
US

V. Phone/Fax

Practice location:
  • Phone: 907-225-0320
  • Fax: 907-247-4819
Mailing address:
  • Phone: 907-225-0320
  • Fax: 907-247-4819

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332800000X
TaxonomyIndian Health Service/Tribal/Urban Indian Health (I/T/U) Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: WENDY ROSS
Title or Position: RCM
Credential:
Phone: 907-228-9254