Provider Demographics
NPI:1922112812
Name:HANNAHVILLE INDIAN COMMUNITY
Entity Type:Organization
Organization Name:HANNAHVILLE INDIAN COMMUNITY
Other - Org Name:HANNAHVILLE HEALTH CENTER PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF HEALTH AND HUMAN SERVIC
Authorized Official - Prefix:
Authorized Official - First Name:GAYLE
Authorized Official - Middle Name:
Authorized Official - Last Name:MESHIGAUD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:906-723-2500
Mailing Address - Street 1:W365 US 2&41
Mailing Address - Street 2:SUITE 600
Mailing Address - City:WILSON
Mailing Address - State:MI
Mailing Address - Zip Code:49896
Mailing Address - Country:US
Mailing Address - Phone:906-723-2560
Mailing Address - Fax:906-723-2566
Practice Address - Street 1:W365 US 2 & 41
Practice Address - Street 2:SUITE 600
Practice Address - City:WILSON
Practice Address - State:MI
Practice Address - Zip Code:49896
Practice Address - Country:US
Practice Address - Phone:906-723-2560
Practice Address - Fax:906-723-2566
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-18
Last Update Date:2017-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5301006526332800000X
333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332800000XSuppliersIndian Health Service/Tribal/Urban Indian Health (I/T/U) Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3318839Medicaid
2043505OtherPK