Healthcare Provider Details

I. General information

NPI: 1346501392
Provider Name (Legal Business Name): FOND DU LAC RESERVATION BUSINESS COMMITTEE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/06/2012
Last Update Date: 09/11/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

927 TRETTEL LN
CLOQUET MN
55720-1345
US

IV. Provider business mailing address

927 TRETTEL LN
CLOQUET MN
55720-1345
US

V. Phone/Fax

Practice location:
  • Phone: 218-879-1227
  • Fax: 218-878-2179
Mailing address:
  • Phone: 218-879-1227
  • Fax: 218-878-2179

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 Number260425
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code3336C0002X
TaxonomyClinic Pharmacy
License Number260425
License Number StateMN

VIII. Authorized Official

Name: MARILYN GROVER
Title or Position: ASSOCIATE DIRECTOR
Credential:
Phone: 218-879-1227