Provider Demographics
NPI:1114217833
Name:KEWEENAW BAY INDIAN COMMUNITY D.A.LAPOINTE HEALTH FACILITY PHARMACY
Entity Type:Organization
Organization Name:KEWEENAW BAY INDIAN COMMUNITY D.A.LAPOINTE HEALTH FACILITY PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:INTERIM HEALTH ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:KATHY
Authorized Official - Middle Name:
Authorized Official - Last Name:MAYO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:906-353-8700
Mailing Address - Street 1:102 SUPERIOR AVE
Mailing Address - Street 2:
Mailing Address - City:BARAGA
Mailing Address - State:MI
Mailing Address - Zip Code:49908-9673
Mailing Address - Country:US
Mailing Address - Phone:906-353-4555
Mailing Address - Fax:906-353-8066
Practice Address - Street 1:102 SUPERIOR AVE
Practice Address - Street 2:
Practice Address - City:BARAGA
Practice Address - State:MI
Practice Address - Zip Code:49908-9673
Practice Address - Country:US
Practice Address - Phone:906-353-4555
Practice Address - Fax:906-353-8066
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:KEWEENAW BAY INDIAN COMMUNITY D,A.LAPOINTE HEALTH FACILITY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-04-14
Last Update Date:2017-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332800000XSuppliersIndian Health Service/Tribal/Urban Indian Health (I/T/U) Pharmacy
No261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1336232289Medicaid