Provider Demographics
NPI:1891708525
Name:CHEYENNE COUNTY HSPTL ASSOCIATION INC
Entity Type:Organization
Organization Name:CHEYENNE COUNTY HSPTL ASSOCIATION INC
Other - Org Name:MEMORIAL HEALTH CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:DANIELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:PHARM D
Authorized Official - Phone:308-254-5070
Mailing Address - Street 1:645 OSAGE ST
Mailing Address - Street 2:
Mailing Address - City:SIDNEY
Mailing Address - State:NE
Mailing Address - Zip Code:69162-1707
Mailing Address - Country:US
Mailing Address - Phone:308-254-8094
Mailing Address - Fax:308-254-8091
Practice Address - Street 1:645 OSAGE ST
Practice Address - Street 2:
Practice Address - City:SIDNEY
Practice Address - State:NE
Practice Address - Zip Code:69162-1707
Practice Address - Country:US
Practice Address - Phone:308-254-8094
Practice Address - Fax:308-254-8091
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-14
Last Update Date:2016-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE25113336I0012X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336I0012XSuppliersPharmacyInstitutional Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2054717OtherPK
NE10025091000Medicaid