=====================================================
General NPI Number Information
=====================================================
NPI Number | 1609116573
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PUEBLO OF SANDIA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/28/2013
-----------------------------------------------------
Last Update Date | 10/01/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 203 SANDIA DAY SCHOOL ROAD
-----------------------------------------------------
City | BERNALILLO
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87004-7076
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 505-867-4696
-----------------------------------------------------
Fax | 505-867-4997
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 481 SANDIA LOOP
-----------------------------------------------------
City | BERNALILLO
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87004-7076
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 505-867-4696
-----------------------------------------------------
Fax | 505-867-4997
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR, HEALTH AND SOCIAL SERVICE
-----------------------------------------------------
Name | MS. CARRIE SARNICKY
-----------------------------------------------------
Credential | MBA
-----------------------------------------------------
Telephone | 505-867-4696
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332800000X
-----------------------------------------------------
Taxonomy Name | Indian Health Service/Tribal/Urban Indian Health (I/T/U) Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------