Provider Demographics
NPI:1295293744
Name:ALEGENT CREIGHTON HEALTH
Entity type:Organization
Organization Name:ALEGENT CREIGHTON HEALTH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIVISION VP PHARMACY
Authorized Official - Prefix:
Authorized Official - First Name:MIKE
Authorized Official - Middle Name:
Authorized Official - Last Name:TIESI
Authorized Official - Suffix:
Authorized Official - Credentials:DO, RP
Authorized Official - Phone:402-343-4546
Mailing Address - Street 1:7261 MERCY ROAD
Mailing Address - Street 2:ATTN: CARIE WILDERMAN /SOUTH BLDG 2ND FLR
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68124
Mailing Address - Country:US
Mailing Address - Phone:402-343-4546
Mailing Address - Fax:
Practice Address - Street 1:1288 VALLEY VIEW DRIVE
Practice Address - Street 2:PHARMACY STE 101
Practice Address - City:COUNCIL BLUFFS
Practice Address - State:IA
Practice Address - Zip Code:51503-5245
Practice Address - Country:US
Practice Address - Phone:000-000-0000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-03-04
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
IAPENDINGMedicaid
IAPENDINGOtherIOWA PHARMACY LICENSE
NEPENDINGOtherNCPDP #
NEPENDINGOtherNCPDP #