Provider Demographics
NPI:1588108260
Name:LITTLE TRAVERSE BAY BANDS OF ODAWA INDIANS
Entity type:Organization
Organization Name:LITTLE TRAVERSE BAY BANDS OF ODAWA INDIANS
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECT SERVICES ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:PHIL
Authorized Official - Middle Name:
Authorized Official - Last Name:HARMON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:231-242-1421
Mailing Address - Street 1:1250 LEARS RD
Mailing Address - Street 2:
Mailing Address - City:PETOSKEY
Mailing Address - State:MI
Mailing Address - Zip Code:49770-9252
Mailing Address - Country:US
Mailing Address - Phone:231-242-1667
Mailing Address - Fax:231-242-1617
Practice Address - Street 1:1250 LEARS RD
Practice Address - Street 2:
Practice Address - City:PETOSKEY
Practice Address - State:MI
Practice Address - Zip Code:49770-9252
Practice Address - Country:US
Practice Address - Phone:231-242-1667
Practice Address - Fax:231-242-1617
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-12-14
Last Update Date:2024-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332800000XSuppliersIndian Health Service/Tribal/Urban Indian Health (I/T/U) Pharmacy