Provider Demographics
NPI:1619396835
Name:ALEGENT CREIGHTON HEALTH
Entity Type:Organization
Organization Name:ALEGENT CREIGHTON HEALTH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SENIOR DIRECTOR OF PHARMACY
Authorized Official - Prefix:
Authorized Official - First Name:MIKE
Authorized Official - Middle Name:
Authorized Official - Last Name:TIESI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:402-343-4546
Mailing Address - Street 1:3135 W BROADWAY
Mailing Address - Street 2:SUITE 101
Mailing Address - City:COUNCIL BLUFFS
Mailing Address - State:IA
Mailing Address - Zip Code:51501-3359
Mailing Address - Country:US
Mailing Address - Phone:712-242-2070
Mailing Address - Fax:712-242-2077
Practice Address - Street 1:3135 W BROADWAY
Practice Address - Street 2:SUITE 101
Practice Address - City:COUNCIL BLUFFS
Practice Address - State:IA
Practice Address - Zip Code:51501-3359
Practice Address - Country:US
Practice Address - Phone:712-242-2070
Practice Address - Fax:712-242-2077
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-04-15
Last Update Date:2017-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE1081OtherNEBRASKA NON RESIDENT MAIL SERVICE PHARMACY
IA0220546Medicaid
NE10026519120Medicaid
IA1504OtherIOWA COMMUNITY PHARMACY PERMIT
IA7482690008Medicare NSC