Basic Information
| Provider Information | |||||||||
| NPI: | 1447701966 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FAIRBANKS MEMORIAL HOSPITAL, LLC | ||||||||
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| OtherOrganizationName: | FAIRBANKS MEMORIAL HOSPITAL PHARMACY | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1650 COWLES ST DEPT 41A | ||||||||
| Address2: | |||||||||
| City: | FAIRBANKS | ||||||||
| State: | AK | ||||||||
| PostalCode: | 997015907 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9074585525 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1650 COWLES ST DEPT 41A | ||||||||
| Address2: | |||||||||
| City: | FAIRBANKS | ||||||||
| State: | AK | ||||||||
| PostalCode: | 997015907 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9074585525 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/19/2016 | ||||||||
| LastUpdateDate: | 10/19/2016 | ||||||||
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| AuthorizedOfficialLastName: | EBENAL | ||||||||
| AuthorizedOfficialFirstName: | SHELLEY | ||||||||
| AuthorizedOfficialMiddleName: | D | ||||||||
| AuthorizedOfficialTitleorPosition: | GENERAL COUNSEL | ||||||||
| AuthorizedOfficialTelephone: | 9074585550 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | FOUNDATION HEALTH, LLC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3336I0012X | Y | Suppliers | Pharmacy | Institutional Pharmacy |
No ID Information.