Healthcare Provider Details

I. General information

NPI: 1093553372
Provider Name (Legal Business Name): EASTERN SHOSHONE TRIBE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/19/2024
Last Update Date: 07/14/2025
Certification Date: 07/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

29 BLACK COAL DR
FORT WASHAKIE WY
82514
US

IV. Provider business mailing address

PO BOX 128
FORT WASHAKIE WY
82514-0128
US

V. Phone/Fax

Practice location:
  • Phone: 307-332-7300
  • Fax:
Mailing address:
  • Phone: 307-332-7300
  • 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 Number
License Number State

VIII. Authorized Official

Name: ANDREW MCALPIN
Title or Position: CHIEF EXECUTIVE OFFICER
Credential: MD
Phone: 307-335-5912