Healthcare Provider Details

I. General information

NPI: 1053447599
Provider Name (Legal Business Name): CASS LAKE INDIAN HOSPITAL PHARMACY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/27/2007
Last Update Date: 10/23/2023
Certification Date: 10/23/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

425 7TH ST NW
CASS LAKE MN
56633-3360
US

IV. Provider business mailing address

PO BOX 95421
CLEVELAND OH
44101-0033
US

V. Phone/Fax

Practice location:
  • Phone: 218-335-3313
  • Fax: 218-335-3352
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code332800000X
TaxonomyIndian Health Service/Tribal/Urban Indian Health (I/T/U) Pharmacy
License Number2603942
License Number StateMN

VIII. Authorized Official

Name: KAILEE FRETLAND
Title or Position: PRINCIPAL PHARMACY CONSULTANT
Credential: PHARMD
Phone: 240-478-2245