Provider Demographics
NPI:1700064714
Name:FOND DU LAC RESERVATION BUSINESS COMMITTEE
Entity Type:Organization
Organization Name:FOND DU LAC RESERVATION BUSINESS COMMITTEE
Other - Org Name:MASHKIKI WAAKAAIGAN PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ASSOCIATE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:MARILYN
Authorized Official - Middle Name:
Authorized Official - Last Name:GROVER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:218-878-2101
Mailing Address - Street 1:927 TRETTEL LANE
Mailing Address - Street 2:FOND DU LAC HUMAN SERVICES DIVISION
Mailing Address - City:CLOQUET
Mailing Address - State:MN
Mailing Address - Zip Code:55720
Mailing Address - Country:US
Mailing Address - Phone:218-879-1227
Mailing Address - Fax:218-878-3755
Practice Address - Street 1:2020 BLOOMINGTON AVE
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55404-3073
Practice Address - Country:US
Practice Address - Phone:612-871-1989
Practice Address - Fax:612-222-3463
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FOND DU LAC HUMAN SERVICES DIVISION
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-02-01
Last Update Date:2017-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN263031332800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes332800000XSuppliersIndian Health Service/Tribal/Urban Indian Health (I/T/U) PharmacyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN2428349OtherNCPDP
MN666815100Medicaid
MN2428349OtherNCPDP
MN666815100Medicaid