Provider Demographics
NPI:1790594349
Name:POKAGON BAND OF POTAWATOMI INDIANS
Entity type:Organization
Organization Name:POKAGON BAND OF POTAWATOMI INDIANS
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:PRISCILLA
Authorized Official - Middle Name:
Authorized Official - Last Name:GATTIES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:269-462-4403
Mailing Address - Street 1:1986 MALL PL
Mailing Address - Street 2:
Mailing Address - City:BENTON HARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:49022-2332
Mailing Address - Country:US
Mailing Address - Phone:269-945-5854
Mailing Address - Fax:269-945-5854
Practice Address - Street 1:1986 MALL PL
Practice Address - Street 2:
Practice Address - City:BENTON HARBOR
Practice Address - State:MI
Practice Address - Zip Code:49022-2332
Practice Address - Country:US
Practice Address - Phone:269-945-5854
Practice Address - Fax:269-945-5854
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-01-07
Last Update Date:2025-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332800000XSuppliersIndian Health Service/Tribal/Urban Indian Health (I/T/U) Pharmacy
No3336C0002XSuppliersPharmacyClinic Pharmacy