Healthcare Provider Details

I. General information

NPI: 1821030446
Provider Name (Legal Business Name): INDIAN HEALTH COUNCIL PHARMACY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/11/2006
Last Update Date: 11/09/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

50100 GOLSH RD
VALLEY CENTER CA
92082
US

IV. Provider business mailing address

PO BOX 406
PAUMA VALLEY CA
92061-0406
US

V. Phone/Fax

Practice location:
  • Phone: 760-749-1410
  • Fax: 760-749-0225
Mailing address:
  • Phone:
  • Fax:

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 NumberPHE30519
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
# 4
Primary TaxonomyN
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: ROBERT SCHOSTAG
Title or Position: PHARMACY DIRECTOR
Credential: RPH
Phone: 760-749-1410