Basic Information
| Provider Information | |||||||||
| NPI: | 1609829100 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | IVY HOME INFUSIONS LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2841 DE BARR RD | ||||||||
| Address2: | STE 20 | ||||||||
| City: | ANCHORAGE | ||||||||
| State: | AK | ||||||||
| PostalCode: | 99508 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9072792425 | ||||||||
| FaxNumber: | 9072792426 | ||||||||
| Practice Location | |||||||||
| Address1: | 2841 DE BARR RD | ||||||||
| Address2: | STE 20 | ||||||||
| City: | ANCHORAGE | ||||||||
| State: | AK | ||||||||
| PostalCode: | 99508 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9072792425 | ||||||||
| FaxNumber: | 9072792426 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/18/2006 | ||||||||
| LastUpdateDate: | 01/22/2018 | ||||||||
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| AuthorizedOfficialLastName: | GIONET | ||||||||
| AuthorizedOfficialFirstName: | PAUL | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 9072792425 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | RPH | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 333600000X | N | Suppliers | Pharmacy | 3336C0004X | N | Suppliers | Pharmacy | Compounding Pharmacy | 3336C0003X | N | Suppliers | Pharmacy | Community/Retail Pharmacy | 3336H0001X | PHAR426 | AK | Y | Suppliers | Pharmacy | Home Infusion Therapy Pharmacy |
ID Information
| ID | Type | State | Issuer | Description | 1996879 | 01 | PK | OTHER | PH7680 | 05 | AK | MEDICAID |