Healthcare Provider Details

I. General information

NPI: 1235280223
Provider Name (Legal Business Name): SOUTHERN INDIAN HEALTH COUNCIL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/16/2007
Last Update Date: 11/12/2024
Certification Date: 11/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4058 WILLOWS RD
ALPINE CA
91901-1668
US

IV. Provider business mailing address

4058 WILLOWS RD
ALPINE CA
91901-1668
US

V. Phone/Fax

Practice location:
  • Phone: 619-445-1188
  • Fax: 619-445-2892
Mailing address:
  • Phone: 619-445-1188
  • Fax: 619-445-2892

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code332800000X
TaxonomyIndian Health Service/Tribal/Urban Indian Health (I/T/U) Pharmacy
License NumberPHE35491
License Number StateCA

VIII. Authorized Official

Name: DEAN GARCIA
Title or Position: PIC
Credential: PHARMD
Phone: 619-445-1188