Basic Information
| Provider Information | |||||||||
| NPI: | 1952436099 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PEDIATRIC HEMATOLOGY ONCOLOGY PHARMACY LTC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1000 E 21ST ST | ||||||||
| Address2: | SUITE 3100 | ||||||||
| City: | SIOUX FALLS | ||||||||
| State: | SD | ||||||||
| PostalCode: | 571051035 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6053227595 | ||||||||
| FaxNumber: | 6053227599 | ||||||||
| Practice Location | |||||||||
| Address1: | 1000 E 21ST ST | ||||||||
| Address2: | SUITE 3100 | ||||||||
| City: | SIOUX FALLS | ||||||||
| State: | SD | ||||||||
| PostalCode: | 571051035 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6053227595 | ||||||||
| FaxNumber: | 6053227599 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/22/2007 | ||||||||
| LastUpdateDate: | 12/07/2010 | ||||||||
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| AuthorizedOfficialLastName: | CHIU | ||||||||
| AuthorizedOfficialFirstName: | YEE-LAI | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PHARMACY MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 6053227595 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | R. PH. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 333600000X | 100-1649 | SD | Y | Suppliers | Pharmacy |
ID Information
| ID | Type | State | Issuer | Description | 4304666 | 01 | SD | NCPDP NUMBER | OTHER |