Provider Demographics
NPI:1265058903
Name:BOIS FORTE RESERVATION TRIBAL GOVERNMENT
Entity type:Organization
Organization Name:BOIS FORTE RESERVATION TRIBAL GOVERNMENT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LYNETTE
Authorized Official - Middle Name:
Authorized Official - Last Name:TAHTINEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:218-757-3650
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:218-757-3650
Mailing Address - Fax:
Practice Address - Street 1:5219 SAINT JOHN DR
Practice Address - Street 2:
Practice Address - City:ORR
Practice Address - State:MN
Practice Address - Zip Code:55771-8232
Practice Address - Country:US
Practice Address - Phone:218-757-3650
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BOIS FORTE RESERVATION TRIBAL GOVERNMENT
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2020-06-18
Last Update Date:2020-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy