Healthcare Provider Details

I. General information

NPI: 1669227203
Provider Name (Legal Business Name): GRAND TRAVERSE BAND OF OTTAWA AND CHIPPEWA INDIANS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/18/2024
Last Update Date: 02/26/2026
Certification Date: 02/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2300 N STALLMAN RD
PESHAWBESTOWN MI
49682-9158
US

IV. Provider business mailing address

2300 N STALLMAN RD
PESHAWBESTOWN MI
49682-9158
US

V. Phone/Fax

Practice location:
  • Phone: 231-534-7350
  • Fax: 231-534-7351
Mailing address:
  • Phone: 231-534-7350
  • Fax: 231-534-7351

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332800000X
TaxonomyIndian Health Service/Tribal/Urban Indian Health (I/T/U) Pharmacy
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3336C0002X
TaxonomyClinic Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: KIMBERLY JANE HINES
Title or Position: PHARMACY MANAGER
Credential: RPH
Phone: 231-543-7350