Healthcare Provider Details

I. General information

NPI: 1376289322
Provider Name (Legal Business Name): SOUTHSHORE TRIBAL HEALTH PHARMACY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/11/2022
Last Update Date: 08/07/2024
Certification Date: 08/07/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14440 OLYMPIC DRIVE SUITE B
CLEARLAKE CA
95422-9545
US

IV. Provider business mailing address

925 BEVINS CT
LAKEPORT CA
95453-9754
US

V. Phone/Fax

Practice location:
  • Phone: 707-263-8382
  • Fax: 707-263-5019
Mailing address:
  • Phone: 707-263-8382
  • Fax: 707-263-5019

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: MR. THOMAS BURNETT
Title or Position: IT SPECIALIST
Credential:
Phone: 707-263-8382