24D2129285 CLIA NUMBER - PHS INDIAN HOSPITAL PHARMACY

Laboratory Demographics

CLIA Number: 24D2129285

Facility Name: PHS INDIAN HOSPITAL PHARMACY

Facility Address:
24760 HOSPITAL DRIVE
REDLAKE, MN
ZIP 56671
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Facility Phone Number: 218 679-0239

Facility Type: Pharmacy

Certificate Type: Waiver

NPI Number: 1063549822

Taxonomy: 332800000X - Indian Health Service/Tribal/Urban Indian Health (I/T/U) Pharmacy
An Indian Health Service/Tribal/Urban Indian Health (I/T/U) Pharmacy means a pharmacy operated by the Indian Health Service, an Indian tribe or tribal organization, or an urban Indian organization, all of which are defined in Section 4 of the Indian Health Care Improvement Act, 25 U.S.C. 1603.

CLIA Record

Field Name	Field Value
CLIA Number	24D2129285
LAB Type	Pharmacy
Facility Name	PHS INDIAN HOSPITAL PHARMACY
Street	24760 HOSPITAL DRIVE
City	REDLAKE
State	MN
ZIP	56671
Phone	218 679-0239
CertificateType	4
CertificateEffectiveDate	4/18/2023
CertificateExpirationDate	4/17/2025
FacilityType	Waiver

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This page was last updated on: 4/23/2024