Provider Demographics
NPI:1699983361
Name:KETCHIKAN INDIAN CORPORATION
Entity type:Organization
Organization Name:KETCHIKAN INDIAN CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:RCM
Authorized Official - Prefix:
Authorized Official - First Name:WENDY
Authorized Official - Middle Name:
Authorized Official - Last Name:ROSS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:907-228-9254
Mailing Address - Street 1:2960 TONGASS AVE
Mailing Address - Street 2:
Mailing Address - City:KETCHIKAN
Mailing Address - State:AK
Mailing Address - Zip Code:99901-5742
Mailing Address - Country:US
Mailing Address - Phone:907-225-0320
Mailing Address - Fax:907-247-4819
Practice Address - Street 1:2960 TONGASS AVE
Practice Address - Street 2:
Practice Address - City:KETCHIKAN
Practice Address - State:AK
Practice Address - Zip Code:99901-5742
Practice Address - Country:US
Practice Address - Phone:907-225-0320
Practice Address - Fax:907-247-4819
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-18
Last Update Date:2023-03-07
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
0202325OtherNCPDP NUMBER
AKPH2696Medicaid
BK6732083OtherPHARMACY DEA