Provider Demographics
NPI:1447838750
Name:UPPER MATTAPONI INDIAN TRIBE
Entity type:Organization
Organization Name:UPPER MATTAPONI INDIAN TRIBE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:STEVE
Authorized Official - Middle Name:
Authorized Official - Last Name:TUPPONCE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:804-347-4109
Mailing Address - Street 1:13476 KING WILLIAM RD
Mailing Address - Street 2:
Mailing Address - City:KING WILLIAM
Mailing Address - State:VA
Mailing Address - Zip Code:23086-3401
Mailing Address - Country:US
Mailing Address - Phone:804-769-0041
Mailing Address - Fax:
Practice Address - Street 1:7864 RICHMOND TAPPAHANNOCK HWY
Practice Address - Street 2:
Practice Address - City:AYLETT
Practice Address - State:VA
Practice Address - Zip Code:23009-3056
Practice Address - Country:US
Practice Address - Phone:804-769-2015
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-03-30
Last Update Date:2023-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy