Provider Demographics
NPI:1841947801
Name:MILLE LACS HEALTH SYSTEM
Entity type:Organization
Organization Name:MILLE LACS HEALTH SYSTEM
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:ROYCE
Authorized Official - Last Name:NELSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:320-532-2580
Mailing Address - Street 1:200 ELM ST N
Mailing Address - Street 2:
Mailing Address - City:ONAMIA
Mailing Address - State:MN
Mailing Address - Zip Code:56359-7901
Mailing Address - Country:US
Mailing Address - Phone:320-532-2492
Mailing Address - Fax:320-532-2499
Practice Address - Street 1:200 ELM ST N
Practice Address - Street 2:
Practice Address - City:ONAMIA
Practice Address - State:MN
Practice Address - Zip Code:56359-7901
Practice Address - Country:US
Practice Address - Phone:320-532-2492
Practice Address - Fax:320-532-2499
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-03-09
Last Update Date:2024-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN266492OtherMINNESOTA BOARD OF PHARMACY