Provider Demographics
NPI:1982729364
Name:MILLE LACS BAND OF OJIBWE INDIANS
Entity Type:Organization
Organization Name:MILLE LACS BAND OF OJIBWE INDIANS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COMMISSIONER OF HEALTH
Authorized Official - Prefix:
Authorized Official - First Name:SAMUEL
Authorized Official - Middle Name:ARCHIE
Authorized Official - Last Name:MOOSE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:320-532-4750
Mailing Address - Street 1:43500 MIGIZI DRIVE
Mailing Address - Street 2:
Mailing Address - City:ONAMIA
Mailing Address - State:MN
Mailing Address - Zip Code:56359
Mailing Address - Country:US
Mailing Address - Phone:320-532-4770
Mailing Address - Fax:320-532-4705
Practice Address - Street 1:43500 MIGIZI DRIVE
Practice Address - Street 2:
Practice Address - City:ONAMIA
Practice Address - State:MN
Practice Address - Zip Code:56359
Practice Address - Country:US
Practice Address - Phone:320-532-4770
Practice Address - Fax:320-532-4705
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-21
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN085753000Medicaid
MN085753000Medicaid
1122893Medicare ID - Type Unspecified