Basic Information
| Provider Information | |||||||||
| NPI: | 1669502316 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CONFEDERATED SALISH & KOOTENAI TRIBES OF THE FLATHEAD RESERVATION | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | CSKT ST. IGNATIUS HEALTH CENTER PHARMACY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 308 MISSION DRIVE | ||||||||
| Address2: | PO BOX 880 | ||||||||
| City: | ST IGNATIUS | ||||||||
| State: | MT | ||||||||
| PostalCode: | 59865 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 35401 MISSION DRIVE | ||||||||
| Address2: | |||||||||
| City: | SAINT IGNATIUS | ||||||||
| State: | MT | ||||||||
| PostalCode: | 59865 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4067453525 | ||||||||
| FaxNumber: | 4067454721 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/06/2007 | ||||||||
| LastUpdateDate: | 07/14/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | DURGLO | ||||||||
| AuthorizedOfficialFirstName: | JOSEPH | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | BUSINESS OFFICE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 4067453525 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | CONFEDERATED SALISH & KOOTENAI TRIBES OF THE FLATHEAD RESERVATION | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 07/14/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 333600000X | N | Suppliers | Pharmacy | 332800000X | Y | Suppliers | Indian Health Service/Tribal/Urban Indian Health (I/T/U) Pharmacy |
ID Information
| ID | Type | State | Issuer | Description | 2706438 | 01 | OTHER ID NUMBER-COMMERCIAL NUMBER | OTHER | 2210104 | 05 | MT | MEDICAID | 0730236 | 05 | MT | MEDICAID |