Provider Demographics
NPI:1386246221
Name:LAGUNA HEALTHCARE CORPORATION
Entity type:Organization
Organization Name:LAGUNA HEALTHCARE CORPORATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHARMACY DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:TISCHA
Authorized Official - Middle Name:
Authorized Official - Last Name:BECKER
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:505-431-0750
Mailing Address - Street 1:PO BOX 549
Mailing Address - Street 2:
Mailing Address - City:PARAJE
Mailing Address - State:NM
Mailing Address - Zip Code:87007-0549
Mailing Address - Country:US
Mailing Address - Phone:505-431-0711
Mailing Address - Fax:505-431-0749
Practice Address - Street 1:6 BASSWOOD RD
Practice Address - Street 2:
Practice Address - City:PARAJE
Practice Address - State:NM
Practice Address - Zip Code:87007
Practice Address - Country:US
Practice Address - Phone:505-431-0750
Practice Address - Fax:505-431-0749
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LAGUNA HEALTHCARE CORP
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2020-11-16
Last Update Date:2021-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes332800000XSuppliersIndian Health Service/Tribal/Urban Indian Health (I/T/U) PharmacyGroup - Multi-Specialty
No1835P2201XPharmacy Service ProvidersPharmacistAmbulatory CareGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM02239540Medicaid