Provider Demographics
NPI:1063678779
Name:THREE AFFILIATED TRIBES MANADREE HEALTH CARE TELE-PHARMACY
Entity Type:Organization
Organization Name:THREE AFFILIATED TRIBES MANADREE HEALTH CARE TELE-PHARMACY
Other - Org Name:TAT MANADREE TELEPHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF TELEPHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:DONNA
Authorized Official - Middle Name:
Authorized Official - Last Name:BIERI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:701-938-3459
Mailing Address - Street 1:PO BOX 625
Mailing Address - Street 2:
Mailing Address - City:MANDAREE
Mailing Address - State:ND
Mailing Address - Zip Code:58757-0625
Mailing Address - Country:US
Mailing Address - Phone:701-759-3151
Mailing Address - Fax:701-759-3181
Practice Address - Street 1:305 MAIN STREET
Practice Address - Street 2:
Practice Address - City:MANDAREE
Practice Address - State:ND
Practice Address - Zip Code:58757
Practice Address - Country:US
Practice Address - Phone:701-759-3151
Practice Address - Fax:701-759-3181
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-01
Last Update Date:2015-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND775332800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332800000XSuppliersIndian Health Service/Tribal/Urban Indian Health (I/T/U) Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2117699OtherPK
ND2404Medicaid