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General NPI Number Information
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NPI Number | 1629256763
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Entity Type | Organization
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Legal Business Name | FOND DU LAC RESERVATION BUSINESS COMMITTEE
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Dates
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Enumeration Date | 01/31/2008
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Last Update Date | 07/21/2022
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Provider Practice Location Address
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Address Line | 221 W 4TH ST
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City | DULUTH
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State | MN
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Zip | 55806-2719
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Country | US
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Telephone | 218-279-4142
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Fax | 218-279-4077
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Provider Business Mailing Address
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Address Line | FOND DU LAC HUMAN SERV DIVISION 927 TRETTEL LANE
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City | CLOQUET
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State | MN
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Zip | 55720
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Country | US
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Telephone | 218-829-1227
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Fax | 218-878-2188
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Authorized Official
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Title or Position | ASSOCIATE DIRECTOR
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Name | MARILYN GROVER
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Credential |
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Telephone | 218-879-1227
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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 | 260913
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License Number State | MN
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