Provider Demographics
NPI:1972613388
Name:CREDENA HEALTH LLC
Entity Type:Organization
Organization Name:CREDENA HEALTH LLC
Other - Org Name:THE BROADWAY PHARMACY
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:AVP/SECRETARY
Authorized Official - Prefix:
Authorized Official - First Name:MIKE
Authorized Official - Middle Name:
Authorized Official - Last Name:SKAFI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:575-650-3396
Mailing Address - Street 1:PO BOX 2704
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97208-2704
Mailing Address - Country:US
Mailing Address - Phone:406-327-1650
Mailing Address - Fax:406-327-1651
Practice Address - Street 1:500 W BROADWAY ST
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59802-4008
Practice Address - Country:US
Practice Address - Phone:406-327-1650
Practice Address - Fax:406-327-1651
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-30
Last Update Date:2023-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT213187Medicaid
MT213187Medicaid