Provider Demographics
NPI:1083700959
Name:ALEGENT CREIGHTON HEALTH
Entity Type:Organization
Organization Name:ALEGENT CREIGHTON HEALTH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SENIOR DIRECTOR OF PHARMACY
Authorized Official - Prefix:
Authorized Official - First Name:MIKE
Authorized Official - Middle Name:
Authorized Official - Last Name:TIESI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:402-343-4546
Mailing Address - Street 1:3308 SAMSON WAY STE 106A
Mailing Address - Street 2:
Mailing Address - City:BELLEVUE
Mailing Address - State:NE
Mailing Address - Zip Code:68123-3235
Mailing Address - Country:US
Mailing Address - Phone:402-291-5076
Mailing Address - Fax:402-293-9464
Practice Address - Street 1:3308 SAMSON WAY STE 106A
Practice Address - Street 2:
Practice Address - City:BELLEVUE
Practice Address - State:NE
Practice Address - Zip Code:68123-3235
Practice Address - Country:US
Practice Address - Phone:402-291-5076
Practice Address - Fax:402-293-9464
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-05
Last Update Date:2017-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X
NE28073336C0003X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE10026519106Medicaid
NE2807OtherNEBRASKA COMMUNITY PHARMACY PERMIT
IA4704OtherLICENSE
IA0204528Medicaid
NE2807OtherNEBRASKA COMMUNITY PHARMACY PERMIT