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General NPI Number Information
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NPI Number | 1376455691
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Entity Type | Organization
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Legal Business Name | LAC VIEUX DESERT BAND OF LAKE SUPERIOR CHIPPEWA INDIANS
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Dates
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Enumeration Date | 09/21/2026
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Last Update Date | 09/21/2026
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Provider Practice Location Address
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Address Line | 4559 WESSON STREET SUITE 100
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City | DETROIT
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State | MI
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Zip | 48210
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Country | US
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Telephone | 313-600-0189
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 9
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City | WATERSMEET
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State | MI
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Zip | 49969-0009
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Country | US
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Telephone | 313-600-0189
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Fax |
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Authorized Official
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Title or Position | ADMINISTRATOR
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Name | SADIE VALLIERE
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Credential |
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Telephone | 906-358-4587
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 332800000X
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Taxonomy Name | Indian Health Service/Tribal/Urban Indian Health (I/T/U) Pharmacy
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 333600000X
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Taxonomy Name | Pharmacy
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License Number |
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License Number State |
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