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General NPI Number Information
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NPI Number | 1669227203
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Entity Type | Organization
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Legal Business Name | GRAND TRAVERSE BAND OF OTTAWA AND CHIPPEWA INDIANS
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Dates
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Enumeration Date | 04/18/2024
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Last Update Date | 11/13/2024
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Provider Practice Location Address
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Address Line | 2300 N STALLMAN RD
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City | SUTTONS BAY
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State | MI
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Zip | 49682-9158
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Country | US
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Telephone | 231-492-4996
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Fax |
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Provider Business Mailing Address
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Address Line | 2300 N STALLMAN RD
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City | SUTTONS BAY
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State | MI
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Zip | 49682-9158
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Country | US
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Telephone | 231-492-4996
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Fax |
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Authorized Official
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Title or Position | PHARMACY MANAGER
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Name | KIM JANE HINES
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Credential | RPH
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Telephone | 231-492-4996
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 3336C0002X
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Taxonomy Name | Clinic 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 | 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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