Provider Demographics
NPI:1053447599
Name:CASS LAKE INDIAN HOSPITAL PHARMACY
Entity Type:Organization
Organization Name:CASS LAKE INDIAN HOSPITAL PHARMACY
Other - Org Name:CASS LAKE INDIAN HOSPITAL PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRINCIPAL PHARMACY CONSULTANT
Authorized Official - Prefix:
Authorized Official - First Name:KAILEE
Authorized Official - Middle Name:
Authorized Official - Last Name:FRETLAND
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:240-478-2245
Mailing Address - Street 1:PO BOX 95421
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44101-0033
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:425 7TH ST NW
Practice Address - Street 2:
Practice Address - City:CASS LAKE
Practice Address - State:MN
Practice Address - Zip Code:56633-3360
Practice Address - Country:US
Practice Address - Phone:218-335-3313
Practice Address - Fax:218-335-3352
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-27
Last Update Date:2023-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2603942332800000X
333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332800000XSuppliersIndian Health Service/Tribal/Urban Indian Health (I/T/U) Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2046504OtherPK
MN966553600Medicaid