1790879070 NPI number — GENEVA WOODS HEALTH SUPPLIES AK, LLC

Table of content: (NPI 1790879070)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790879070 NPI number — GENEVA WOODS HEALTH SUPPLIES AK, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GENEVA WOODS HEALTH SUPPLIES AK, LLC
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:
MYMEDSUPPLIES
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:
1790879070
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/30/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3674 E COUNTRY FIELD CIR STE C
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WASILLA
Provider Business Mailing Address State Name:
AK
Provider Business Mailing Address Postal Code:
99654-5101
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
907-631-4475
Provider Business Mailing Address Fax Number:
866-498-9635

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3674 E COUNTRY FIELD CIR STE C
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WASILLA
Provider Business Practice Location Address State Name:
AK
Provider Business Practice Location Address Postal Code:
99654
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
907-631-4475
Provider Business Practice Location Address Fax Number:
866-498-9635
Provider Enumeration Date:
10/03/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
SYCKS
Authorized Official First Name:
AARON
Authorized Official Middle Name:
Authorized Official Title or Position:
CEO/AUTHORIZED OFFICIAL
Authorized Official Telephone Number:
206-697-1892

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 332BP3500X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 332BX2000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 1678549 , issued by the state of ( AK ) . This identifiers is of the category "MEDICAID".