1063432672 NPI number — CORAM ALTERNATE SITE SERVICES INC

Table of content: (NPI 1063432672)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063432672 NPI number — CORAM ALTERNATE SITE SERVICES INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CORAM ALTERNATE SITE SERVICES INC
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:
CORAM CVS/SPECIALTY INFUSION SERVICES
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:
1063432672
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/07/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 809160
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHICAGO
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60680-9160
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
303-672-8631
Provider Business Mailing Address Fax Number:
303-298-0047

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
180 PASSAIC AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FAIRFIELD
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
07004-3516
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
973-756-5963
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/20/2006

Additional Information

Authorized Official

Authorized Official Last Name:
LACAVICH
Authorized Official First Name:
TRICIA
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
314-306-3255

Provider Taxonomy Codes

  • Taxonomy code: 251E00000X , with the licence number:  HP0218401 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 251F00000X , with the licence number: HP0218401 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 28RS00527400 . This is a "RX LICENSE" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: 3137064 . This is a "NCPDP" identifier . This identifiers is of the category "OTHER".




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