Provider Demographics
NPI:1568592137
Name:SPIRIT LAKE HEALTH CENTER PHARMACY
Entity Type:Organization
Organization Name:SPIRIT LAKE HEALTH CENTER PHARMACY
Other - Org Name:SPIRIT LAKE HEALTH CENTER PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACY PROGRAM SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:
Authorized Official - Last Name:CUMMINGS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:405-951-6086
Mailing Address - Street 1:SPIRIT LAKE HEALTH CTR
Mailing Address - Street 2:3100 SOLUTIONS CENTER
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-3001
Mailing Address - Country:US
Mailing Address - Phone:701-766-1612
Mailing Address - Fax:701-766-1625
Practice Address - Street 1:3883 74TH AVE NE
Practice Address - Street 2:
Practice Address - City:FORT TOTTEN
Practice Address - State:ND
Practice Address - Zip Code:58335
Practice Address - Country:US
Practice Address - Phone:701-766-1612
Practice Address - Fax:701-766-1625
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-06
Last Update Date:2013-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332800000XSuppliersIndian Health Service/Tribal/Urban Indian Health (I/T/U) Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND01051Medicaid
ND1061SPMedicaid
3503693OtherNCPDP PROVIDER IDENTIFICATION NUMBER
5764240001Medicare NSC