Healthcare Provider Details

I. General information

NPI: 1801900766
Provider Name (Legal Business Name): DHEW IND HLTH SV HLTH SVS & MNTL HLTH ADM
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/18/2006
Last Update Date: 05/19/2023
Certification Date: 05/19/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4212 N 16TH ST
PHOENIX AZ
85016-5319
US

IV. Provider business mailing address

PO BOX 95460
CLEVELAND OH
44101-0033
US

V. Phone/Fax

Practice location:
  • Phone: 602-263-1200
  • Fax: 602-263-1619
Mailing address:
  • Phone: 602-581-6088
  • Fax: 602-263-1619

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 NumberAZS07912
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code3336S0011X
TaxonomySpecialty Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: LAURA A TILLMAN
Title or Position: CHIEF MEDICAL OFFICER
Credential: MD
Phone: 602-263-1567