MEDICARE: ALEGENT CREIGHTON HEALTH

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	332B00000X	Durable Medical Equipment & Medical Supplies
2	3336C0003X	Community/Retail Pharmacy	2416	NE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	2416	OTHER	NE	NEBRASKA COMMUNITY PHARMACY PERMIT
3	4622	OTHER	IA	IOWA LICENSE
4	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1023104999
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ALEGENT CREIGHTON HEALTH

Provider Business Mailing Address
First Line	:	8613 N 30TH ST
Second Line	:
City	:	OMAHA
State	:	NE
Zip	:	68112-1852
Country	:	US
Telephone Number	:	402-451-2125
Fax Number	:	402-451-2401

Provider Business Practice Location Address
First Line	:	8613 N 30TH ST
Second Line	:
City	:	OMAHA
State	:	NE
Zip	:	68112-1852
Country	:	US
Telephone Number	:	402-451-2125
Fax Number	:	402-451-2401

Authorized Official
Title or Position	:	SENIOR DIRECTOR OF PHARMACY
Name	:	MIKE TIESI
Credential	:
Telephone Number	:	402-343-4546

Provider Enumeration Date	:	10/05/2006
Last Update Date	:	10/23/2017

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Directions to “ALEGENT CREIGHTON HEALTH ” Practice Location

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