Healthcare Provider Details

I. General information

NPI: 1265058903
Provider Name (Legal Business Name): BOIS FORTE RESERVATION TRIBAL GOVERNMENT
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/18/2020
Last Update Date: 06/18/2020
Certification Date: 06/18/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5219 SAINT JOHN DR
ORR MN
55771-8232
US

IV. Provider business mailing address

5219 SAINT JOHN DR
ORR MN
55771-8232
US

V. Phone/Fax

Practice location:
  • Phone: 218-757-3650
  • Fax:
Mailing address:
  • Phone: 218-757-3650
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: LYNETTE TAHTINEN
Title or Position: BUSINESS MANAGER
Credential:
Phone: 218-757-3650