MEDICARE: FOND DU LAC RESERVATION BUSINESS COMMITTEE

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	332800000X	Indian Health Service/Tribal/Urban Indian Health (I/T/U) Pharmacy	260913	MN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	2047381	OTHER		PK

General Provider Information

NPI Number	:	1629256763
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FOND DU LAC RESERVATION BUSINESS COMMITTEE

Provider Business Mailing Address
First Line	:	FOND DU LAC HUMAN SERV DIVISION
Second Line	:	927 TRETTEL LANE
City	:	CLOQUET
State	:	MN
Zip	:	55720
Country	:	US
Telephone Number	:	218-829-1227
Fax Number	:	218-878-2188

Provider Business Practice Location Address
First Line	:	221 W 4TH ST
Second Line	:
City	:	DULUTH
State	:	MN
Zip	:	55806-2719
Country	:	US
Telephone Number	:	218-279-4142
Fax Number	:	218-279-4077

Authorized Official
Title or Position	:	ASSOCIATE DIRECTOR
Name	:	MARILYN GROVER
Credential	:
Telephone Number	:	218-879-1227

Provider Enumeration Date	:	01/31/2008
Last Update Date	:	07/21/2022

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