Provider Demographics
NPI:1699881540
Name:TUOLUMNE ME-WUK INDIAN HEALTH CENTER
Entity type:Organization
Organization Name:TUOLUMNE ME-WUK INDIAN HEALTH CENTER
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHARMACY DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JOO YEUN
Authorized Official - Middle Name:
Authorized Official - Last Name:SEO
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:209-928-5407
Mailing Address - Street 1:18880 CHERRY VALLEY BLVD.
Mailing Address - Street 2:
Mailing Address - City:TUOLUMNE
Mailing Address - State:CA
Mailing Address - Zip Code:95379-9506
Mailing Address - Country:US
Mailing Address - Phone:209-928-5400
Mailing Address - Fax:209-928-5413
Practice Address - Street 1:18880 CHERRY VALLEY BLVD.
Practice Address - Street 2:
Practice Address - City:TUOLUMNE
Practice Address - State:CA
Practice Address - Zip Code:95379-9506
Practice Address - Country:US
Practice Address - Phone:209-928-5400
Practice Address - Fax:209-928-5413
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-22
Last Update Date:2023-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332800000X
CAPHY482303336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332800000XSuppliersIndian Health Service/Tribal/Urban Indian Health (I/T/U) Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2115109OtherPK
CAPHA482300Medicaid