Healthcare Provider Details

I. General information

NPI: 1275606808
Provider Name (Legal Business Name): RED CLIFF BAND OF :AKE SUPERIOR
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/15/2006
Last Update Date: 07/19/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

36745 AIKEN RD
BAYFIELD WI
54814-4579
US

IV. Provider business mailing address

36745 AIKEN RD
BAYFIELD WI
54814-4579
US

V. Phone/Fax

Practice location:
  • Phone: 715-779-3157
  • Fax: 715-779-3501
Mailing address:
  • Phone: 715-779-3157
  • Fax: 715-779-3752

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 Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code3336C0002X
TaxonomyClinic Pharmacy
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: RICHARD PETERSON
Title or Position: TRIBAL CHAIRMAN
Credential:
Phone: 715-779-3700