Basic Information
Provider Information | |||||||||
NPI: | 1629256763 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | FOND DU LAC RESERVATION BUSINESS COMMITTEE | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | FOND DU LAC CAIR PHARMACY | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | FOND DU LAC HUMAN SERV DIVISION | ||||||||
Address2: | 927 TRETTEL LANE | ||||||||
City: | CLOQUET | ||||||||
State: | MN | ||||||||
PostalCode: | 55720 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2188291227 | ||||||||
FaxNumber: | 2188782188 | ||||||||
Practice Location | |||||||||
Address1: | 221 W 4TH ST | ||||||||
Address2: |   | ||||||||
City: | DULUTH | ||||||||
State: | MN | ||||||||
PostalCode: | 558062719 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2182794142 | ||||||||
FaxNumber: | 2182794077 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/31/2008 | ||||||||
LastUpdateDate: | 07/21/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | GROVER | ||||||||
AuthorizedOfficialFirstName: | MARILYN | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | ASSOCIATE DIRECTOR | ||||||||
AuthorizedOfficialTelephone: | 2188791227 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332800000X | 260913 | MN | Y |   | Suppliers | Indian Health Service/Tribal/Urban Indian Health (I/T/U) Pharmacy |   |
ID Information
ID | Type | State | Issuer | Description | 66815100 | 05 | MN |   | MEDICAID | 2047381 | 01 |   | PK | OTHER |