Provider Demographics
NPI:1164809778
Name:CREDENA HEALTH LLC
Entity Type:Organization
Organization Name:CREDENA HEALTH LLC
Other - Org Name:CREDENA HEALTH PHARMACY LAKESHORE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:AVP/SECRETARY
Authorized Official - Prefix:
Authorized Official - First Name:MIKE
Authorized Official - Middle Name:
Authorized Official - Last Name:SKAFI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:575-650-3396
Mailing Address - Street 1:PO BOX 2704
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97208-2704
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:50331A US HIGHWAY 93
Practice Address - Street 2:
Practice Address - City:POLSON
Practice Address - State:MT
Practice Address - Zip Code:59860-7046
Practice Address - Country:US
Practice Address - Phone:406-883-0342
Practice Address - Fax:406-883-0469
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-05-04
Last Update Date:2023-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2151758OtherPK
MT2784090Medicaid