Healthcare Provider Details

I. General information

NPI: 1932989977
Provider Name (Legal Business Name): RIVERSIDE-SAN BERNARDINO COUNTY INDIAN HEALTH, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/05/2023
Last Update Date: 10/05/2023
Certification Date: 10/03/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

CAHUILLA INDIAN HEALTH CLINIC PHARMACY 53000 CAHUILLA ROAD
ANZA CA
92539-9142
US

IV. Provider business mailing address

11980 MOUNT VERNON AVE
GRAND TERRACE CA
92313-5172
US

V. Phone/Fax

Practice location:
  • Phone: 951-763-4835
  • Fax: 951-763-0495
Mailing address:
  • Phone: 909-864-1097
  • Fax: 951-225-6879

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: WILLIAM THOMSEN
Title or Position: CEO
Credential:
Phone: 909-864-1097