PHS Indian Hospital

Primary specialty

Indian Health Service/Tribal/Urban Indian Health (I/T/U) PharmacyTaxonomy code 332800000X

License

2604653 Issued in MN

Legal business name

PHS INDIAN HOSPITAL

Doing business as

Red Lake Indian Hospital Pharmacy

Practice address

24670 Hospital Drive
Red Lake, MN 56671

Phone

(218) 679-0173

Fax

(218) 679-0189

NPI assigned

Feb 28, 2007

Last updated

Jan 19, 2024By the provider in NPPES

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Jan Thunder

Title

Business Office Manager

Phone

(218) 679-0148

Specialties & licenses 4

Addresses

Other identifiers 2

Other names 1

• RED LAKE INDIAN HOSPITAL PHARMACY Doing business as

Medicare fee-for-service enrollment

Enrolled in MN

Enrollment records 1

Other NPIs with the same Medicare PAC ID 1

NPIs whose Medicare enrollments share a PECOS associate control ID (the same enrolled entity).

• PHS Indian Hospital

  • General Acute Care Hospital
  • Red Lake, MN
  • NPI 1508809765

  4789598731

  Same PAC ID

Locations

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1172620800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1705622400000",
    "number": "1063549822",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "4100 W. 150TH ST",
            "address_2": "LB: 95419",
            "city": "CLEVELAND",
            "state": "OH",
            "postal_code": "44135"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "24670 HOSPITAL DRIVE",
            "city": "RED LAKE",
            "state": "MN",
            "postal_code": "56671",
            "telephone_number": "218-679-0173",
            "fax_number": "218-679-0189"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "PHS INDIAN HOSPITAL",
        "organizational_subpart": "NO",
        "enumeration_date": "2007-02-28",
        "last_updated": "2024-01-19",
        "certification_date": "2024-01-17",
        "status": "A",
        "authorized_official_last_name": "THUNDER",
        "authorized_official_first_name": "JAN",
        "authorized_official_title_or_position": "BUSINESS OFFICE MANAGER",
        "authorized_official_telephone_number": "218-679-0148"
    },
    "taxonomies": [
        {
            "code": "332B00000X",
            "taxonomy_group": "",
            "desc": "Durable Medical Equipment & Medical Supplies",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "332800000X",
            "taxonomy_group": "",
            "desc": "Indian Health Service/Tribal/Urban Indian Health (I/T/U) Pharmacy",
            "state": "MN",
            "license": "2604653",
            "primary": true
        },
        {
            "code": "3336C0002X",
            "taxonomy_group": "",
            "desc": "Pharmacy, Clinic Pharmacy",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "3336S0011X",
            "taxonomy_group": "",
            "desc": "Pharmacy, Specialty Pharmacy",
            "state": "NU",
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "476753500",
            "state": "MN"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "PK",
            "identifier": "2046533",
            "state": null
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "RED LAKE INDIAN HOSPITAL PHARMACY",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "RED LAKE INDIAN HOSPITAL PHARMACY",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

• Susan Lucy Ninham
• Connie Jean Norman, CHW
• Amelia Olson, PHARMD
• Luke Joseph Peltier, PHARMD
• Pharmacy Dept. PHS Indian Hopsital
• PHS Indian Hospital
• PHS Indian Hospital (PHS Indian Hospital-Dental)
• PHS Indian Hospital (PHS Indian Hospital-Behavior Health Clinic)
• John J Pieniazek, M.D.
• Ponemah Clinic

• Indian Health Service/Tribal/Urban Indian Health (I/T/U) Pharmacy in Red Lake, MN
• Providers in Red Lake, MN by specialty
• Indian Health Service/Tribal/Urban Indian Health (I/T/U) Pharmacy in Minnesota

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jan 19, 2024; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.