Provider Demographics
NPI:1568521466
Name:FREMONT HEALTH
Entity Type:Organization
Organization Name:FREMONT HEALTH
Other - Org Name:FAMCARE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:PATRICK
Authorized Official - Middle Name:M
Authorized Official - Last Name:BOOTH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:402-721-1610
Mailing Address - Street 1:450 EAST 23RD STREET
Mailing Address - Street 2:
Mailing Address - City:FREMONT
Mailing Address - State:NE
Mailing Address - Zip Code:68025-2303
Mailing Address - Country:US
Mailing Address - Phone:402-721-1610
Mailing Address - Fax:402-727-3433
Practice Address - Street 1:450 EAST 23RD STREET
Practice Address - Street 2:
Practice Address - City:FREMONT
Practice Address - State:NE
Practice Address - Zip Code:68025-2303
Practice Address - Country:US
Practice Address - Phone:402-727-3820
Practice Address - Fax:402-727-3517
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FREMONT HEALTH
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-12-06
Last Update Date:2016-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE23613336C0003X, 3336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes3336C0003XSuppliersPharmacyCommunity/Retail PharmacyGroup - Multi-Specialty
No3336L0003XSuppliersPharmacyLong Term Care PharmacyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE=========50Medicaid