Provider Demographics
NPI:1144359852
Name:GILA RIVER HEALTH CARE CORPORATION
Entity type:Organization
Organization Name:GILA RIVER HEALTH CARE CORPORATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR, PHARMACY
Authorized Official - Prefix:
Authorized Official - First Name:LARRY
Authorized Official - Middle Name:
Authorized Official - Last Name:CROLL
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:602-528-1200
Mailing Address - Street 1:17487 S HEALTHCARE DR
Mailing Address - Street 2:
Mailing Address - City:LAVEEN
Mailing Address - State:AZ
Mailing Address - Zip Code:85339-8500
Mailing Address - Country:US
Mailing Address - Phone:520-550-6022
Mailing Address - Fax:520-550-6028
Practice Address - Street 1:17487 S HEALTHCARE DR
Practice Address - Street 2:
Practice Address - City:LAVEEN
Practice Address - State:AZ
Practice Address - Zip Code:85339-8500
Practice Address - Country:US
Practice Address - Phone:520-550-6022
Practice Address - Fax:520-550-6028
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-06
Last Update Date:2017-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332800000XSuppliersIndian Health Service/Tribal/Urban Indian Health (I/T/U) Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
1991256OtherPK
AZAHCCCS334582Medicaid