1437194206 NPI number — GREAT LAND INFUSION PHARMACY INC

Table of content: (NPI 1437194206)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1437194206 NPI number — GREAT LAND INFUSION PHARMACY INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GREAT LAND INFUSION PHARMACY 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:
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:
1437194206
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/27/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 230368, GREAT LAND INFUSION PHARMACY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ANCHORAGE
Provider Business Mailing Address State Name:
AK
Provider Business Mailing Address Postal Code:
99523
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
907-561-2421
Provider Business Mailing Address Fax Number:
907-868-5154

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2421 E TUDOR RD
Provider Second Line Business Practice Location Address:
STE 107
Provider Business Practice Location Address City Name:
ANCHORAGE
Provider Business Practice Location Address State Name:
AK
Provider Business Practice Location Address Postal Code:
99507-1128
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
907-561-2421
Provider Business Practice Location Address Fax Number:
907-868-5154
Provider Enumeration Date:
06/17/2006

Additional Information

Authorized Official

Authorized Official Last Name:
NOAEILL
Authorized Official First Name:
DOUGLAS
Authorized Official Middle Name:
SCOTT
Authorized Official Title or Position:
PRESIDENT/OWNER
Authorized Official Telephone Number:
907-561-2421

Provider Taxonomy Codes

  • Taxonomy code: 3336C0003X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336H0001X , with the licence number: 429 , registered in the state of AK ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 3336S0011X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 1997065 . This is a "PK" identifier . This identifiers is of the category "OTHER".
  • Identifier: PH0429 , issued by the state of ( AK ) . This identifiers is of the category "MEDICAID".
  • Identifier: MS0429 , issued by the state of ( AK ) . This identifiers is of the category "MEDICAID".




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