Provider Demographics
NPI:1700968211
Name:W.A. FOOTE MEMORIAL HOSPITAL, INC.
Entity Type:Organization
Organization Name:W.A. FOOTE MEMORIAL HOSPITAL, INC.
Other - Org Name:ALLEGIANCE HEALTH PHARMACY #7743
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SR VP FINANCE/CFO
Authorized Official - Prefix:MS
Authorized Official - First Name:JEANNE
Authorized Official - Middle Name:M
Authorized Official - Last Name:WICKENS
Authorized Official - Suffix:
Authorized Official - Credentials:CFO
Authorized Official - Phone:517-841-6979
Mailing Address - Street 1:2200 SPRINGPORT RD
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MI
Mailing Address - Zip Code:49202-1432
Mailing Address - Country:US
Mailing Address - Phone:517-787-7053
Mailing Address - Fax:
Practice Address - Street 1:2200 SPRINGPORT RD
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MI
Practice Address - Zip Code:49202-1432
Practice Address - Country:US
Practice Address - Phone:517-787-7053
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-20
Last Update Date:2014-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5301006737183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty