Provider Demographics
NPI:1578679411
Name:GREATER FAIRBANKS COMM
Entity Type:Organization
Organization Name:GREATER FAIRBANKS COMM
Other - Org Name:FAIRBANKS MEMORIAL HOSPITAL PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIR OF PHCY
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:COTTER
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:907-458-5621
Mailing Address - Street 1:1650 COWLES ST
Mailing Address - Street 2:DEPT 41 A
Mailing Address - City:FAIRBANKS
Mailing Address - State:AK
Mailing Address - Zip Code:99701-5907
Mailing Address - Country:US
Mailing Address - Phone:907-458-5610
Mailing Address - Fax:907-458-5622
Practice Address - Street 1:1650 COWLES ST
Practice Address - Street 2:DEPT 41 A
Practice Address - City:FAIRBANKS
Practice Address - State:AK
Practice Address - Zip Code:99701-5907
Practice Address - Country:US
Practice Address - Phone:907-458-5610
Practice Address - Fax:907-458-5622
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-22
Last Update Date:2016-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AKPHAR3953336I0012X
3336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336I0012XSuppliersPharmacyInstitutional Pharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKPH7525Medicaid
1997054OtherPK