Provider Demographics
NPI:1851428288
Name:FORT BERTHOLD IHS HEALTH CENTER PHARMACY
Entity Type:Organization
Organization Name:FORT BERTHOLD IHS HEALTH CENTER PHARMACY
Other - Org Name:MINNIE-TOHE HEALTH CENTER
Other - Org Type:Other Name
Authorized Official - Title/Position:IHS AREA PHARMACY CONSULTANT
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:FORMAN
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:605-226-7212
Mailing Address - Street 1:1 MINNI TOHE DR
Mailing Address - Street 2:PO BOX 400
Mailing Address - City:NEW TOWN
Mailing Address - State:ND
Mailing Address - Zip Code:58763-4400
Mailing Address - Country:US
Mailing Address - Phone:701-627-4701
Mailing Address - Fax:701-627-4318
Practice Address - Street 1:1 MINNI TOHE DR
Practice Address - Street 2:
Practice Address - City:NEW TOWN
Practice Address - State:ND
Practice Address - Zip Code:58763-4400
Practice Address - Country:US
Practice Address - Phone:701-627-4701
Practice Address - Fax:701-627-4318
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-27
Last Update Date:2023-03-07
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
ND1068MIMedicaid
3503845OtherNCPDP NUMBER
3503845OtherNCPDP NUMBER