1154493666 NPI number — MANIILAQ HEALTH CENTER PHARMACY

Table of content: (NPI 1154493666)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1154493666 NPI number — MANIILAQ HEALTH CENTER PHARMACY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MANIILAQ HEALTH CENTER PHARMACY
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:
MANIILAQ HEALTH CENTER PHARMACY
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:
1154493666
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/13/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 43
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
KOTZEBUE
Provider Business Mailing Address State Name:
AK
Provider Business Mailing Address Postal Code:
99752-0043
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5TH ST AND GRIZZLEY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
KOTZEBUE
Provider Business Practice Location Address State Name:
AK
Provider Business Practice Location Address Postal Code:
99752
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
907-442-7182
Provider Business Practice Location Address Fax Number:
907-442-7309
Provider Enumeration Date:
11/14/2006

Additional Information

Authorized Official

Authorized Official Last Name:
KANIKI
Authorized Official First Name:
FREDDY
Authorized Official Middle Name:
Authorized Official Title or Position:
PHRM CHIEF
Authorized Official Telephone Number:
907-442-7336

Provider Taxonomy Codes

  • Taxonomy code: 332800000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: HS190P , issued by the state of ( AK ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1996986 . This is a "PK" identifier . This identifiers is of the category "OTHER".




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