Provider Demographics
NPI:1689605263
Name:JEFFERSON COUNTY MEMORIAL HOSPITAL FOUNDATION, INC.
Entity Type:Organization
Organization Name:JEFFERSON COUNTY MEMORIAL HOSPITAL FOUNDATION, INC.
Other - Org Name:FW HUSTON PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT OF BOARD OF DIRECTORS
Authorized Official - Prefix:MS
Authorized Official - First Name:TAMARA
Authorized Official - Middle Name:
Authorized Official - Last Name:GIGSTAD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:913-774-4340
Mailing Address - Street 1:509 DELAWARE STREET
Mailing Address - Street 2:
Mailing Address - City:OSKALOOSA
Mailing Address - State:KS
Mailing Address - Zip Code:66066
Mailing Address - Country:US
Mailing Address - Phone:785-863-3401
Mailing Address - Fax:785-863-3405
Practice Address - Street 1:509 DELAWARE STREET
Practice Address - Street 2:
Practice Address - City:OSKALOOSA
Practice Address - State:KS
Practice Address - Zip Code:66066
Practice Address - Country:US
Practice Address - Phone:785-863-3401
Practice Address - Fax:785-863-3405
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-05
Last Update Date:2016-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS2096583336C0003X
3336C0003X, 3336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100444240BMedicaid