Provider Demographics
NPI:1730696154
Name:RED LAKE CHEMICAL HEALTH PROGRAMS
Entity type:Organization
Organization Name:RED LAKE CHEMICAL HEALTH PROGRAMS
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PROJECT DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:REYNA
Authorized Official - Middle Name:CRUZ
Authorized Official - Last Name:GONZALEZ-RIVERA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:218-679-3392
Mailing Address - Street 1:P.O. BOX 114
Mailing Address - Street 2:
Mailing Address - City:RED LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:56671
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:14414 GREEN LAKE ROAD
Practice Address - Street 2:
Practice Address - City:REDBY
Practice Address - State:MN
Practice Address - Zip Code:56670
Practice Address - Country:US
Practice Address - Phone:218-679-3868
Practice Address - Fax:218-679-3398
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-01-08
Last Update Date:2018-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332800000XSuppliersIndian Health Service/Tribal/Urban Indian Health (I/T/U) Pharmacy