Healthcare Provider Details

I. General information

NPI: 1467550475
Provider Name (Legal Business Name): PUEBLO OF SAN FELIPE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/21/2006
Last Update Date: 06/11/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3 CEDAR ST SAN FELIPE PUEBLO
SAN FELIPE NM
87001
US

IV. Provider business mailing address

PO BOX 4342 PO BOX 4339
SAN FELIPE NM
87001
US

V. Phone/Fax

Practice location:
  • Phone: 505-867-5485
  • Fax: 505-771-9940
Mailing address:
  • Phone: 505-867-9616
  • Fax: 505-771-9940

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 Number
License Number State

VIII. Authorized Official

Name: DARYL CANDELARIA
Title or Position: TRIBAL ADMIN
Credential: PHARMD RPH
Phone: 505-867-3381