| Organization Name: | MENOMINEE INDIAN TRIBE OF WISCONSIN |
| NPI Number: | 1972545010 |
| Entity Type Code: | Organizational (2) |
| Authorized Official Name: | JERRY L WAUKAU (HEALTH ADMINISTRATOR) |
| Mailing Address: | W3275 Wolf River Road Keshena |
| State: | WI US |
| Postal Code: | 54135 |
| Phone Number: | 7157993361 |
| Fax Number: | 7157993099 |
| NPI Enumeration Date: | 06/12/2006 |
| NPI Last Update Date: | 10/25/2007 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 3336C0002X |
| License Number: | 7848-042 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | WI |
| Taxonomy Type: | Suppliers |
| Taxonomy Classification: | Pharmacy |
| Taxonomy Specialization: | Clinic Pharmacy |
| Taxonomy Definition: | A pharmacy in a clinic, emergency room or hospital (outpatient) that dispenses medications to patients for self-administration under the supervision of a pharmacist. |