Provider Demographics
NPI:1487171054
Name:GERALD L. IGNACE INDIAN HEALTH CENTER, INC.
Entity type:Organization
Organization Name:GERALD L. IGNACE INDIAN HEALTH CENTER, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHARMACY DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:GEORGETTE
Authorized Official - Middle Name:K
Authorized Official - Last Name:LUCEY-DURRANI
Authorized Official - Suffix:
Authorized Official - Credentials:RPH, PHARM D
Authorized Official - Phone:414-316-5000
Mailing Address - Street 1:930 W HISTORIC MITCHELL ST
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53204-3533
Mailing Address - Country:US
Mailing Address - Phone:920-809-6488
Mailing Address - Fax:
Practice Address - Street 1:930 W HISTORIC MITCHELL ST
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53204-3533
Practice Address - Country:US
Practice Address - Phone:920-809-6488
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GERALD L. IGNACE INDIAN HEALTH CENTER, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-08-24
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI9467333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI=========Medicaid