Healthcare Provider Details

I. General information

NPI: 1902954944
Provider Name (Legal Business Name): RIVERSIDE SAN BERNARDINO COUNTY INDIAN HEALTH INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/08/2007
Last Update Date: 03/29/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11555 1/2 POTRERO RD
BANNING CA
92220-6946
US

IV. Provider business mailing address

11980 MOUNT VERNON AVE
GRAND TERRACE CA
92313-5172
US

V. Phone/Fax

Practice location:
  • Phone: 951-849-4761
  • Fax: 951-849-0681
Mailing address:
  • Phone: 909-864-1097
  • Fax: 909-503-1969

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code332800000X
TaxonomyIndian Health Service/Tribal/Urban Indian Health (I/T/U) Pharmacy
License NumberPHY32790
License Number StateCA

VIII. Authorized Official

Name: SUE YOON
Title or Position: DIRECTOR OF PHARMACY
Credential: BS
Phone: 909-864-1097