Healthcare Provider Details

I. General information

NPI: 1265884308
Provider Name (Legal Business Name): SPIRIT LAKE TRIBE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/12/2016
Last Update Date: 07/12/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3883 74TH AVE NE
FORT TOTTEN ND
58335
US

IV. Provider business mailing address

PO BOX 309
FORT TOTTEN ND
58335-0309
US

V. Phone/Fax

Practice location:
  • Phone: 701-766-1612
  • Fax: 701-766-1625
Mailing address:
  • Phone: 701-766-1612
  • Fax: 701-766-1625

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0002X
TaxonomyClinic Pharmacy
License NumberPHAR713
License Number StateND

VIII. Authorized Official

Name: LYNDE MONSON
Title or Position: CHIEF PHARMACIST
Credential: PHARMD
Phone: 701-766-1612