NPIMap

Organization Active NPI

Menominee Indian Tribe of Wisconsin

  • Clinic Pharmacy
  • Keshena, WI
National Provider Identifier
1972545010
Registry record updated Mar 7, 2023
On this page

Key facts

NPPES NPI Registry
Primary specialty
Clinic PharmacyTaxonomy code 3336C0002X
License
7848-042 Issued in WI
Legal business name
MENOMINEE INDIAN TRIBE OF WISCONSIN
Practice address
W3275 Wolf River Road
Keshena, WI 54135
Phone
(715) 799-3361
Fax
(715) 799-3099
NPI assigned
Jun 12, 2006
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Mar 7, 2023

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

Authorized official

Name
Jerry L Waukau Sr.
Title
Health Administrator
Phone
(715) 799-3361

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Clinic Pharmacy 3336C0002X 7848-042 WI Primary

Addresses

Primary practice location

W3275 Wolf River Road
Keshena, WI 54135

Mailing address

PO Box 970
Keshena, WI 54135-0970
Phone (715) 799-3361

Other identifiers 2

IdentifierTypeStateIssuer
32955700MedicaidWI
5118446OtherNAPB #

Other names 1

  • Menominee Tribal Clinic Pharmacy Doing business as

National Provider Directory

National Provider Directory
Tax ID family
Menominee Tribl Res SQ7 organizations share this tax ID, including this one

Other organizations with this tax ID 6

Organizations that report the same tax identification number in the National Provider Directory.

NPI Registry JSON

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

{
    "created_epoch": "1150070400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1678147200000",
    "number": "1972545010",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 970",
            "city": "KESHENA",
            "state": "WI",
            "postal_code": "541350970",
            "telephone_number": "715-799-3361",
            "fax_number": "715-799-3099"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "W3275 WOLF RIVER ROAD",
            "city": "KESHENA",
            "state": "WI",
            "postal_code": "54135",
            "telephone_number": "715-799-3361",
            "fax_number": "715-799-3099"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "MENOMINEE INDIAN TRIBE OF WISCONSIN",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-06-12",
        "last_updated": "2023-03-07",
        "status": "A",
        "authorized_official_last_name": "WAUKAU",
        "authorized_official_first_name": "JERRY",
        "authorized_official_middle_name": "L",
        "authorized_official_title_or_position": "HEALTH ADMINISTRATOR",
        "authorized_official_telephone_number": "715-799-3361",
        "authorized_official_name_suffix": "Sr."
    },
    "taxonomies": [
        {
            "code": "3336C0002X",
            "taxonomy_group": "",
            "desc": "Pharmacy, Clinic Pharmacy",
            "state": "WI",
            "license": "7848-042",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "32955700",
            "state": "WI"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "NAPB #",
            "identifier": "5118446",
            "state": null
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Menominee Tribal Clinic Pharmacy",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Keshena, WI

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Mar 7, 2023; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.