Provider Demographics
NPI:1316904337
Name:BAY MILLS INDIAN COMMUNITY
Entity type:Organization
Organization Name:BAY MILLS INDIAN COMMUNITY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:HEALTH - HUMAN SERVICES DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:AUDREY
Authorized Official - Middle Name:
Authorized Official - Last Name:BREAKIE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:906-248-8327
Mailing Address - Street 1:12455 W LAKESHORE DR
Mailing Address - Street 2:
Mailing Address - City:BRIMLEY
Mailing Address - State:MI
Mailing Address - Zip Code:49715-9327
Mailing Address - Country:US
Mailing Address - Phone:906-248-2031
Mailing Address - Fax:906-248-2032
Practice Address - Street 1:12455 W LAKESHORE DR
Practice Address - Street 2:
Practice Address - City:BRIMLEY
Practice Address - State:MI
Practice Address - Zip Code:49715-9327
Practice Address - Country:US
Practice Address - Phone:906-248-2031
Practice Address - Fax:906-248-8366
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-26
Last Update Date:2022-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332800000XSuppliersIndian Health Service/Tribal/Urban Indian Health (I/T/U) Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2362438Medicaid
MI2362438OtherNAPB
MI874998658Medicaid