Provider Demographics
NPI:1922024876
Name:WHITE EARTH INDIAN HEALTH CENTER PHARMACY
Entity type:Organization
Organization Name:WHITE EARTH INDIAN HEALTH CENTER PHARMACY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DEPUTY CEO
Authorized Official - Prefix:
Authorized Official - First Name:LEEANN
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:THORSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:218-983-6303
Mailing Address - Street 1:40520 COUNTY HIGHWAY 34
Mailing Address - Street 2:
Mailing Address - City:OGEMA
Mailing Address - State:MN
Mailing Address - Zip Code:56569-9612
Mailing Address - Country:US
Mailing Address - Phone:218-983-4300
Mailing Address - Fax:218-983-6384
Practice Address - Street 1:40520 COUNTY HIGHWAY 34
Practice Address - Street 2:
Practice Address - City:OGEMA
Practice Address - State:MN
Practice Address - Zip Code:56569-9612
Practice Address - Country:US
Practice Address - Phone:218-983-6375
Practice Address - Fax:218-983-6384
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WHITE EARTH INDIAN HEALTH CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-07-14
Last Update Date:2022-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332800000XSuppliersIndian Health Service/Tribal/Urban Indian Health (I/T/U) Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2047418OtherPK
MN246753400Medicaid