Provider Demographics
NPI:1124220900
Name:JICARILLA IHS PHARMACY
Entity type:Organization
Organization Name:JICARILLA IHS PHARMACY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHARMACY PROGRAM SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:
Authorized Official - Last Name:CUMMINGS
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:405-951-6086
Mailing Address - Street 1:PO BOX 95447
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44101-0033
Mailing Address - Country:US
Mailing Address - Phone:575-759-3291
Mailing Address - Fax:575-759-3532
Practice Address - Street 1:500 N MUNDO DR
Practice Address - Street 2:
Practice Address - City:DULCE
Practice Address - State:NM
Practice Address - Zip Code:87528-5176
Practice Address - Country:US
Practice Address - Phone:505-759-3291
Practice Address - Fax:505-759-3532
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-04
Last Update Date:2023-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332800000XSuppliersIndian Health Service/Tribal/Urban Indian Health (I/T/U) Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM000K3526Medicaid
3210248OtherNCPDP PROVIDER IDENTIFICATION NUMBER