Healthcare Provider Details

I. General information

NPI: 1316904337
Provider Name (Legal Business Name): BAY MILLS INDIAN COMMUNITY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/26/2006
Last Update Date: 10/04/2022
Certification Date: 10/04/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12455 W LAKESHORE DR
BRIMLEY MI
49715-9327
US

IV. Provider business mailing address

12455 W LAKESHORE DR
BRIMLEY MI
49715-9327
US

V. Phone/Fax

Practice location:
  • Phone: 906-248-2031
  • Fax: 906-248-8366
Mailing address:
  • Phone: 906-248-2031
  • Fax: 906-248-2032

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332800000X
TaxonomyIndian Health Service/Tribal/Urban Indian Health (I/T/U) Pharmacy
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: MRS. AUDREY BREAKIE
Title or Position: HEALTH - HUMAN SERVICES DIRECTOR
Credential:
Phone: 906-248-8327