Basic Information
| Provider Information | |||||||||
| NPI: | 1902342306 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SOUTHEAST ALASKA REGIONAL HEALTH CONSORTIUM | ||||||||
| LastName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | SEARHC WRANGELL PHARMACY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 3100 CHANNEL DRIVE | ||||||||
| Address2: | |||||||||
| City: | JUNEAU | ||||||||
| State: | AK | ||||||||
| PostalCode: | 99801 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9074634074 | ||||||||
| FaxNumber: | 9074631510 | ||||||||
| Practice Location | |||||||||
| Address1: | 232 WOOD STREET | ||||||||
| Address2: | |||||||||
| City: | WRANGELL | ||||||||
| State: | AK | ||||||||
| PostalCode: | 999299992 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9078747000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/10/2017 | ||||||||
| LastUpdateDate: | 03/01/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | HARRIS | ||||||||
| AuthorizedOfficialFirstName: | DANIEL | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | VP/CHIEF FINANCIAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 9074634000 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 03/01/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 333600000X | N | Suppliers | Pharmacy | 3336C0003X | N | Suppliers | Pharmacy | Community/Retail Pharmacy | 332800000X | Y | Suppliers | Indian Health Service/Tribal/Urban Indian Health (I/T/U) Pharmacy |
ID Information
| ID | Type | State | Issuer | Description | 172234 | 01 | AK | STATE OF ALASKA | OTHER | 2168617 | 01 | PK | OTHER | 1667455 | 05 | AK | MEDICAID |