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FQHC638544 Menominee Indian Tribe of Wisconsin (Active)
Main Details
Name
Menominee Indian Tribe of Wisconsin
Subdivision Name
Menominee Tribal Clinic
Type
Tribal Contract/Compact with IHS (P.L. 93-638)
340B ID
FQHC638544
Contacts
Authorizing Official
Menominee Tribal Clinic
Jerry Waukau, Tribal Health Administrator
(715) 799-5482
Primary Contact
Menominee Indian Tribe of WI
Theodore Houston, Pharmacy Director
(715) 799-3368
Additional Details
Current Program Status
Active
Registration Date
10/3/2016
Participating Start Date
1/1/2017
Participating Approval Date
12/9/2016
Last Recertification Date
2/5/2024
Addresses
Street Address
W3275 WOLF RIVER ROAD
Keshena, WI 54135
Billing Address
Same as Street Address
Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
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