Provider Demographics
NPI:1447273438
Name:WASHOE TRIBE OF NEVADA AND CALIFORNIA
Entity type:Organization
Organization Name:WASHOE TRIBE OF NEVADA AND CALIFORNIA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CLINIC DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:LOREN
Authorized Official - Middle Name:
Authorized Official - Last Name:ELLERY
Authorized Official - Suffix:
Authorized Official - Credentials:PHARM D
Authorized Official - Phone:775-265-4215
Mailing Address - Street 1:1559 WATASHEAMU RD
Mailing Address - Street 2:
Mailing Address - City:GARDNERVILLE
Mailing Address - State:NV
Mailing Address - Zip Code:89460-7455
Mailing Address - Country:US
Mailing Address - Phone:775-265-4215
Mailing Address - Fax:775-265-6071
Practice Address - Street 1:1559 WATASHEAMU RD
Practice Address - Street 2:
Practice Address - City:GARDNERVILLE
Practice Address - State:NV
Practice Address - Zip Code:89460-7455
Practice Address - Country:US
Practice Address - Phone:775-265-4215
Practice Address - Fax:775-265-6071
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-25
Last Update Date:2014-12-10
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
NV00470300Medicaid
NV004703001Medicaid
2056708OtherPK