Provider Demographics
NPI:1760739601
Name:SOUTHCENTRAL FOUNDATION
Entity Type:Organization
Organization Name:SOUTHCENTRAL FOUNDATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP FINANCE
Authorized Official - Prefix:
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:OLSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:907-729-4939
Mailing Address - Street 1:1001 S KNIK GOOSE BAY RD
Mailing Address - Street 2:
Mailing Address - City:WASILLA
Mailing Address - State:AK
Mailing Address - Zip Code:99654-8083
Mailing Address - Country:US
Mailing Address - Phone:907-631-7800
Mailing Address - Fax:907-631-7619
Practice Address - Street 1:1001 S KNIK GOOSE BAY RD
Practice Address - Street 2:
Practice Address - City:WASILLA
Practice Address - State:AK
Practice Address - Zip Code:99654-8083
Practice Address - Country:US
Practice Address - Phone:907-631-7800
Practice Address - Fax:907-631-7619
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-08-09
Last Update Date:2014-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK20467332800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332800000XSuppliersIndian Health Service/Tribal/Urban Indian Health (I/T/U) Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK920086076OtherEIN