1336272095 NPI number — BRISTOL BAY AREA HEALTH CORPORATION

Table of content: (NPI 1336272095)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1336272095 NPI number — BRISTOL BAY AREA HEALTH CORPORATION

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BRISTOL BAY AREA HEALTH CORPORATION
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
KANAKANAK PHARMACY
Provider Other Organization Name Type Code:
5
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1336272095
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/07/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 130
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DILLINGHAM
Provider Business Mailing Address State Name:
AK
Provider Business Mailing Address Postal Code:
99576-0130
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
907-842-5201
Provider Business Mailing Address Fax Number:
904-842-9250

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6000 KANAKANAK ROAD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DILLINGHAM
Provider Business Practice Location Address State Name:
AK
Provider Business Practice Location Address Postal Code:
99576
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
907-842-5201
Provider Business Practice Location Address Fax Number:
907-842-9250
Provider Enumeration Date:
03/13/2007

Additional Information

Authorized Official

Authorized Official Last Name:
CLARK
Authorized Official First Name:
ROBERT
Authorized Official Middle Name:
J
Authorized Official Title or Position:
CHIEF EXECUTIVE OFFICER
Authorized Official Telephone Number:
907-842-5201

Provider Taxonomy Codes

  • Taxonomy code: 333600000X , with the licence number:  345 , registered in the state of AK ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 0202123 . This is a "NABP" identifier . This identifiers is of the category "OTHER".
  • Identifier: PH0067 , issued by the state of ( AK ) . This identifiers is of the category "MEDICAID".




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