Provider Demographics
NPI:1871695270
Name:SOUTH PENNISULA HOSPITAL PHCY
Entity type:Organization
Organization Name:SOUTH PENNISULA HOSPITAL PHCY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:RPH
Authorized Official - Prefix:
Authorized Official - First Name:MIKE
Authorized Official - Middle Name:
Authorized Official - Last Name:OSTROM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:907-235-0257
Mailing Address - Street 1:4300 BARTLETT ST
Mailing Address - Street 2:
Mailing Address - City:HOMER
Mailing Address - State:AK
Mailing Address - Zip Code:99603-7005
Mailing Address - Country:US
Mailing Address - Phone:907-235-0257
Mailing Address - Fax:907-235-0848
Practice Address - Street 1:4300 BARTLETT ST
Practice Address - Street 2:
Practice Address - City:HOMER
Practice Address - State:AK
Practice Address - Zip Code:99603-7005
Practice Address - Country:US
Practice Address - Phone:907-235-0257
Practice Address - Fax:907-235-0848
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-05
Last Update Date:2020-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK2323336I0012X
3336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336I0012XSuppliersPharmacyInstitutional Pharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
1996579OtherPK
1996579OtherPK