Healthcare Provider Details

I. General information

NPI: 1912205378
Provider Name (Legal Business Name): SHOSHONE PAIUTE TRIBES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/09/2011
Last Update Date: 04/07/2015
Certification Date:
Deactivation Date: 08/13/2013
Reactivation Date: 12/11/2013

III. Provider practice location address

1623 HOSPITAL LOOP
OWYHEE NV
89832-1200
US

IV. Provider business mailing address

PO BOX 130
OWYHEE NV
89832-0130
US

V. Phone/Fax

Practice location:
  • Phone: 775-757-2415
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code3336S0011X
TaxonomySpecialty Pharmacy
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: RULAN STANDS
Title or Position: ACTING TRIBAL ADMINISTRATOR
Credential:
Phone: 775-757-2415