Healthcare Provider Details

I. General information

NPI: 1063549822
Provider Name (Legal Business Name): PHS INDIAN HOSPITAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/28/2007
Last Update Date: 01/19/2024
Certification Date: 01/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24670 HOSPITAL DRIVE
RED LAKE MN
56671
US

IV. Provider business mailing address

4100 W. 150TH ST LB: 95419
CLEVELAND OH
44135
US

V. Phone/Fax

Practice location:
  • Phone: 218-679-0173
  • Fax: 218-679-0189
Mailing address:
  • Phone:
  • Fax:

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 Number2604653
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code3336C0002X
TaxonomyClinic Pharmacy
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code3336S0011X
TaxonomySpecialty Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: JAN THUNDER
Title or Position: BUSINESS OFFICE MANAGER
Credential:
Phone: 218-679-0148