Healthcare Provider Details

I. General information

NPI: 1760728380
Provider Name (Legal Business Name): PECHANGA INDIAN HEALTH CLINIC PHARMACY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/31/2012
Last Update Date: 10/07/2021
Certification Date: 10/07/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

47001 PALA RD
TEMECULA CA
92592-2925
US

IV. Provider business mailing address

12784 PECHANGA RD
TEMECULA CA
92592
US

V. Phone/Fax

Practice location:
  • Phone: 951-676-6810
  • Fax: 951-676-6421
Mailing address:
  • Phone: 951-676-6810
  • Fax: 951-676-6421

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 Number50823
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code3336C0002X
TaxonomyClinic Pharmacy
License Number
License Number State

VIII. Authorized Official

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