Organization
DHEW IND HLTH SV HLTH SVS & MNTL HLTH ADM
Active
Other names
PIMC Pharmacy
Organization subpart
No
Provider details
NPI number
Authorized official
LAURA A TILLMAN MD (CHIEF MEDICAL OFFICER)
(602) 263-1567
Entity
Organization
Contact information
Practice address
4212 N 16TH ST, PHOENIX, AZ 85016-5319
(602) 263-1200
(602) 263-1619
Mailing address
PO BOX 95460, CLEVELAND, OH 44101-0033
(602) 581-6088
(602) 263-1619
Taxonomy
Speciality
Code
Description
License number
State
332800000X
Indian Health Service/Tribal/Urban Indian Health (I/T/U) Pharmacy
Primary
AZS07912
AZ
3336S0011X
Specialty Pharmacy
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
022062
—
AZ
01
—
0324602
NCPDP PROVIDER IDENTIFICATION NUMBER
—
Enumeration date
08/18/2006
Last updated
05/19/2023
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