Healthcare Provider Details

I. General information

NPI: 1114217833
Provider Name (Legal Business Name): KEWEENAW BAY INDIAN COMMUNITY D.A.LAPOINTE HEALTH FACILITY PHARMACY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/14/2011
Last Update Date: 12/20/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

102 SUPERIOR AVE
BARAGA MI
49908-9673
US

IV. Provider business mailing address

102 SUPERIOR AVE
BARAGA MI
49908-9673
US

V. Phone/Fax

Practice location:
  • Phone: 906-353-4555
  • Fax: 906-353-8066
Mailing address:
  • Phone: 906-353-4555
  • Fax: 906-353-8066

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code332800000X
TaxonomyIndian Health Service/Tribal/Urban Indian Health (I/T/U) Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: MS. KATHY MAYO
Title or Position: INTERIM HEALTH ADMINISTRATOR
Credential:
Phone: 906-353-8700