1780753632 NPI number — ALEGENT CREIGHTON HEALTH

Table of content: (NPI 1780753632)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1780753632 NPI number — ALEGENT CREIGHTON HEALTH

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ALEGENT CREIGHTON HEALTH
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
CHI HEALTH PHARMACY-LAKESIDE
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1780753632
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/27/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
16909 LAKESIDE HILLS CT
Provider Second Line Business Mailing Address:
STE 107
Provider Business Mailing Address City Name:
OMAHA
Provider Business Mailing Address State Name:
NE
Provider Business Mailing Address Postal Code:
68130-4664
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
402-758-5006
Provider Business Mailing Address Fax Number:
402-758-5094

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
16909 LAKESIDE HILLS CT
Provider Second Line Business Practice Location Address:
STE 107
Provider Business Practice Location Address City Name:
OMAHA
Provider Business Practice Location Address State Name:
NE
Provider Business Practice Location Address Postal Code:
68130-4664
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
402-758-5006
Provider Business Practice Location Address Fax Number:
402-758-5094
Provider Enumeration Date:
11/07/2006

Additional Information

Authorized Official

Authorized Official Last Name:
HAZEN
Authorized Official First Name:
MATTHEW
Authorized Official Middle Name:
Authorized Official Title or Position:
DIRECTOR
Authorized Official Telephone Number:
402-343-4546

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0002X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0003X , with the licence number: 2661 , registered in the state of NE ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 10026519109 , issued by the state of ( NE ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2814879 . This is a "NCPDP PROVIDER IDENTIFICATION NUMBER" identifier . This identifiers is of the category "OTHER".




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