1316082167 NPI number — GLACIER VIEW TLC PHARMACY

Table of content: (NPI 1316082167)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1316082167 NPI number — GLACIER VIEW TLC PHARMACY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GLACIER VIEW TLC 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:
Provider Other Organization Name Type Code:
6
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:
1316082167
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/19/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 32960
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JUNEAU
Provider Business Mailing Address State Name:
AK
Provider Business Mailing Address Postal Code:
99803-2960
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
907-789-7570
Provider Business Mailing Address Fax Number:
866-431-1898

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9109 MENDENHALL MALL RD
Provider Second Line Business Practice Location Address:
SUITE 7-A
Provider Business Practice Location Address City Name:
JUNEAU
Provider Business Practice Location Address State Name:
AK
Provider Business Practice Location Address Postal Code:
99801-7113
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
907-789-7570
Provider Business Practice Location Address Fax Number:
866-431-1898
Provider Enumeration Date:
02/20/2007

Additional Information

Authorized Official

Authorized Official Last Name:
POOLE
Authorized Official First Name:
MARSHA
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER/PHARMACIST IN CHARGE
Authorized Official Telephone Number:
907-789-7570

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 333600000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336H0001X , with the licence number: 455 , registered in the state of AK ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0227935 . This is a "NCPDP PROVIDER IDENTIFICATION NUMBER" identifier . This identifiers is of the category "OTHER".




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