Provider Demographics
NPI:1376960666
Name:SIERRA SPECIALTY PHARMACY LLC
Entity Type:Organization
Organization Name:SIERRA SPECIALTY PHARMACY LLC
Other - Org Name:SIERRA SPECIALTY PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BRANT
Authorized Official - Middle Name:
Authorized Official - Last Name:SKANSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:775-853-3500
Mailing Address - Street 1:9738 S VIRGINIA ST STE F
Mailing Address - Street 2:
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89511-4811
Mailing Address - Country:US
Mailing Address - Phone:775-853-3502
Mailing Address - Fax:
Practice Address - Street 1:9738 S VIRGINIA ST STE F
Practice Address - Street 2:
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89511-4811
Practice Address - Country:US
Practice Address - Phone:775-853-3502
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-03-25
Last Update Date:2014-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVPH031083336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1376960666Medicaid
2144777OtherPK