Provider Demographics
NPI:1669227203
Name:GRAND TRAVERSE BAND OF OTTAWA AND CHIPPEWA INDIANS
Entity type:Organization
Organization Name:GRAND TRAVERSE BAND OF OTTAWA AND CHIPPEWA INDIANS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACY MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KIM
Authorized Official - Middle Name:JANE
Authorized Official - Last Name:HINES
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:231-492-4996
Mailing Address - Street 1:2300 N STALLMAN RD
Mailing Address - Street 2:
Mailing Address - City:SUTTONS BAY
Mailing Address - State:MI
Mailing Address - Zip Code:49682-9158
Mailing Address - Country:US
Mailing Address - Phone:231-492-4996
Mailing Address - Fax:
Practice Address - Street 1:2300 N STALLMAN RD
Practice Address - Street 2:
Practice Address - City:SUTTONS BAY
Practice Address - State:MI
Practice Address - Zip Code:49682-9158
Practice Address - Country:US
Practice Address - Phone:231-492-4996
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-04-18
Last Update Date:2024-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332800000XSuppliersIndian Health Service/Tribal/Urban Indian Health (I/T/U) Pharmacy
No3336C0002XSuppliersPharmacyClinic Pharmacy