| Organization Name: | JICARILLA IHS PHARMACY |
| NPI Number: | 1124220900 |
| Entity Type Code: | Organizational (2) |
| Authorized Official Name: | JAMES CUMMINGS (PHARMACY PROGRAM SPECIALIST) |
| Mailing Address: | 12000 Stone Lake Rd Dulce |
| State: | NM US |
| Postal Code: | 87528 |
| Phone Number: | 5057593291 |
| Fax Number: | 5057593532 |
| NPI Enumeration Date: | 06/04/2007 |
| NPI Last Update Date: | 03/05/2013 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 332800000X |
| License Number: | |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | |
| Taxonomy Type: | Suppliers |
| Taxonomy Classification: | Indian Health Service/Tribal/Urban Indian Health (I/T/U) Pharmacy |
| Taxonomy Specialization: | |
| Taxonomy Definition: | An Indian Health Service/Tribal/Urban Indian Health (I/T/U) Pharmacy means a pharmacy operated by the Indian Health Service, an Indian tribe or tribal organization, or an urban Indian organization, all of which are defined in Section 4 of the Indian Health Care Improvement Act, 25 U.S.C. 1603. |