Healthcare Provider Details

I. General information

NPI: 1922112812
Provider Name (Legal Business Name): HANNAHVILLE INDIAN COMMUNITY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/18/2006
Last Update Date: 04/06/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

W365 US 2 & 41 SUITE 600
WILSON MI
49896
US

IV. Provider business mailing address

W365 US 2&41 SUITE 600
WILSON MI
49896
US

V. Phone/Fax

Practice location:
  • Phone: 906-723-2560
  • Fax: 906-723-2566
Mailing address:
  • Phone: 906-723-2560
  • Fax: 906-723-2566

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 Number5301006526
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State

VIII. Authorized Official

Name: GAYLE MESHIGAUD
Title or Position: DIRECTOR OF HEALTH AND HUMAN SERVIC
Credential:
Phone: 906-723-2500