Provider Demographics
NPI:1457819922
Name:PROVIDENCE MEDICAL CENTER
Entity Type:Organization
Organization Name:PROVIDENCE MEDICAL CENTER
Other - Org Name:PROVIDENCE COMMUNITY PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACY DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:
Authorized Official - Last Name:LUEDERS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:402-375-7920
Mailing Address - Street 1:1200 PROVIDENCE RD
Mailing Address - Street 2:
Mailing Address - City:WAYNE
Mailing Address - State:NE
Mailing Address - Zip Code:68787-1212
Mailing Address - Country:US
Mailing Address - Phone:402-375-7920
Mailing Address - Fax:402-375-7605
Practice Address - Street 1:803 PROVIDENCE RD STE 101
Practice Address - Street 2:
Practice Address - City:WAYNE
Practice Address - State:NE
Practice Address - Zip Code:68787-1590
Practice Address - Country:US
Practice Address - Phone:402-375-8862
Practice Address - Fax:402-375-8863
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-03-04
Last Update Date:2019-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy