Provider Demographics
NPI:1144765843
Name:BOIS FORTE RESERVATION TRIBAL GOVERNMENT
Entity Type:Organization
Organization Name:BOIS FORTE RESERVATION TRIBAL GOVERNMENT
Other - Org Name:NEW MOON
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:PAMELA
Authorized Official - Middle Name:
Authorized Official - Last Name:HUGHES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:218-757-3295
Mailing Address - Street 1:5219 SAINT JOHN DR
Mailing Address - Street 2:
Mailing Address - City:ORR
Mailing Address - State:MN
Mailing Address - Zip Code:55771-8232
Mailing Address - Country:US
Mailing Address - Phone:218-757-3295
Mailing Address - Fax:
Practice Address - Street 1:1224 WHITE PINE CIR
Practice Address - Street 2:
Practice Address - City:TOWER
Practice Address - State:MN
Practice Address - Zip Code:55790
Practice Address - Country:US
Practice Address - Phone:218-757-3131
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-01-04
Last Update Date:2018-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332800000XSuppliersIndian Health Service/Tribal/Urban Indian Health (I/T/U) Pharmacy