Provider Demographics
NPI:1629184957
Name:CORAM ALTERNATE SITE SERVICES INC
Entity Type:Organization
Organization Name:CORAM ALTERNATE SITE SERVICES INC
Other - Org Name:CORAM CVS/SPECIALTY INFUSION SERVICES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:TRICIA
Authorized Official - Middle Name:
Authorized Official - Last Name:LACAVICH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:314-306-3255
Mailing Address - Street 1:PO BOX 809160
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60680-9160
Mailing Address - Country:US
Mailing Address - Phone:303-672-8631
Mailing Address - Fax:303-298-0047
Practice Address - Street 1:8370 WOLF LAKE DR STE 107
Practice Address - Street 2:
Practice Address - City:BARTLETT
Practice Address - State:TN
Practice Address - Zip Code:38133-7108
Practice Address - Country:US
Practice Address - Phone:615-630-9279
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CORAM ALTERNATE SITE SERVICES INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-08-21
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
251E00000X, 251F00000X, 261QI0500X
TN0000002058332BP3500X, 333600000X, 3336C0003X, 3336M0002X, 3336H0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336H0001XSuppliersPharmacyHome Infusion Therapy Pharmacy
No251E00000XAgenciesHome Health
Yes251F00000XAgenciesHome Infusion
No261QI0500XAmbulatory Health Care FacilitiesClinic/CenterInfusion Therapy
No332BP3500XSuppliersDurable Medical Equipment & Medical SuppliesParenteral & Enteral Nutrition
No333600000XSuppliersPharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336M0002XSuppliersPharmacyMail Order Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN0000002058OtherRX LICENSE
4429420OtherNCPDP
4429420OtherNCPDP
TN0976970045Medicare NSC