1619396835 NPI number — ALEGENT CREIGHTON HEALTH

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1619396835 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:
Provider Other Organization Name Type Code:
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:
1619396835
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/23/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3135 W BROADWAY
Provider Second Line Business Mailing Address:
SUITE 101
Provider Business Mailing Address City Name:
COUNCIL BLUFFS
Provider Business Mailing Address State Name:
IA
Provider Business Mailing Address Postal Code:
51501-3359
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
712-242-2070
Provider Business Mailing Address Fax Number:
712-242-2077

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3135 W BROADWAY
Provider Second Line Business Practice Location Address:
SUITE 101
Provider Business Practice Location Address City Name:
COUNCIL BLUFFS
Provider Business Practice Location Address State Name:
IA
Provider Business Practice Location Address Postal Code:
51501-3359
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
712-242-2070
Provider Business Practice Location Address Fax Number:
712-242-2077
Provider Enumeration Date:
04/15/2014

Additional Information

Authorized Official

Authorized Official Last Name:
TIESI
Authorized Official First Name:
MIKE
Authorized Official Middle Name:
Authorized Official Title or Position:
SENIOR DIRECTOR OF PHARMACY
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: 3336C0003X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1081 . This is a "NEBRASKA NON RESIDENT MAIL SERVICE PHARMACY" identifier , issued by the state of ( NE ) . This identifiers is of the category "OTHER".
  • Identifier: 0220546 , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 10026519120 , issued by the state of ( NE ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1504 . This is a "IOWA COMMUNITY PHARMACY PERMIT" identifier , issued by the state of ( IA ) . This identifiers is of the category "OTHER".




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