Basic Information
| Provider Information | |||||||||
| NPI: | 1700064714 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FOND DU LAC RESERVATION BUSINESS COMMITTEE | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | MASHKIKI WAAKAAIGAN PHARMACY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 927 TRETTEL LANE | ||||||||
| Address2: | FOND DU LAC HUMAN SERVICES DIVISION | ||||||||
| City: | CLOQUET | ||||||||
| State: | MN | ||||||||
| PostalCode: | 55720 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2188791227 | ||||||||
| FaxNumber: | 2188783755 | ||||||||
| Practice Location | |||||||||
| Address1: | 2020 BLOOMINGTON AVE | ||||||||
| Address2: | |||||||||
| City: | MINNEAPOLIS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554043073 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6128711989 | ||||||||
| FaxNumber: | 6122223463 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/01/2008 | ||||||||
| LastUpdateDate: | 10/12/2017 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | GROVER | ||||||||
| AuthorizedOfficialFirstName: | MARILYN | ||||||||
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| AuthorizedOfficialTitleorPosition: | ASSOCIATE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 2188782101 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | FOND DU LAC HUMAN SERVICES DIVISION | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332800000X | 263031 | MN | Y | Suppliers | Indian Health Service/Tribal/Urban Indian Health (I/T/U) Pharmacy |
ID Information
| ID | Type | State | Issuer | Description | 2428349 | 01 | MN | NCPDP | OTHER | 666815100 | 05 | MN | MEDICAID |