Provider Demographics
NPI:1689232241
Name:MATCH-E-BE-NASH-SHE-WISH BAND OF POTTAWATOMI INDIANS
Entity Type:Organization
Organization Name:MATCH-E-BE-NASH-SHE-WISH BAND OF POTTAWATOMI INDIANS
Other - Org Name:GUN LAKE TRIBE PHARMACY
Other - Org Type:Other Name
Authorized Official - Title/Position:HEALTH AND HUMAN SERVICES DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:
Authorized Official - Last Name:WESAW
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:269-397-1760
Mailing Address - Street 1:2880 MISSION DR
Mailing Address - Street 2:
Mailing Address - City:SHELBYVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:49344-9580
Mailing Address - Country:US
Mailing Address - Phone:269-397-1760
Mailing Address - Fax:
Practice Address - Street 1:2880 MISSION DR
Practice Address - Street 2:
Practice Address - City:SHELBYVILLE
Practice Address - State:MI
Practice Address - Zip Code:49344-9580
Practice Address - Country:US
Practice Address - Phone:269-397-1760
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-05-30
Last Update Date:2019-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy