1255387767 NPI number — CORAM ALTERNATE SITE SERVICES, INC.

Table of content: (NPI 1255387767)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1255387767 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:
1255387767
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/15/2024
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:
480-765-5043
Provider Business Mailing Address Fax Number:
401-733-0211

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2140 NEW MARKET PKWY
Provider Second Line Business Practice Location Address:
SUITE 106
Provider Business Practice Location Address City Name:
MARIETTA
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30067-8766
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
770-952-3021
Provider Business Practice Location Address Fax Number:
770-952-6840
Provider Enumeration Date:
05/26/2006

Additional Information

Authorized Official

Authorized Official Last Name:
WEINERT
Authorized Official First Name:
CRAIG
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
401-765-1500

Provider Taxonomy Codes

  • Taxonomy code: 251E00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 251F00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QI0500X , with the licence number: N/A , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 332B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 332BP3500X , with the licence number: PHRE006180 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 333600000X , with the licence number: PHRE006180 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0003X , with the licence number: PHRE006180 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336H0001X , with the licence number: PHRE006180 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 3336M0002X , with the licence number: -PHRE006180 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 000676255B , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: PHRE006180 . This is a "RX LICENSE" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 00676255A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000676255E , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1141819 . This is a "NCPDP" identifier . This identifiers is of the category "OTHER".




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