Provider Demographics
NPI:1528796851
Name:LITTLE RIVER BAND OF OTTAWA INDIANS
Entity type:Organization
Organization Name:LITTLE RIVER BAND OF OTTAWA INDIANS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:KEITH
Authorized Official - Middle Name:
Authorized Official - Last Name:JACQUE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:231-398-6853
Mailing Address - Street 1:2608 GOVERNMENT CENTER DR
Mailing Address - Street 2:
Mailing Address - City:MANISTEE
Mailing Address - State:MI
Mailing Address - Zip Code:49660-8302
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4905 HARVEY ST
Practice Address - Street 2:
Practice Address - City:NORTON SHORES
Practice Address - State:MI
Practice Address - Zip Code:49444-9763
Practice Address - Country:US
Practice Address - Phone:231-398-6853
Practice Address - Fax:231-723-1523
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LITTLE RIVER BAND OF OTTAWA INDIANS PHARMACY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2022-08-14
Last Update Date:2023-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336C0002XSuppliersPharmacyClinic Pharmacy
No332800000XSuppliersIndian Health Service/Tribal/Urban Indian Health (I/T/U) Pharmacy