Healthcare Provider Details

I. General information

NPI: 1073551131
Provider Name (Legal Business Name): PRODIGY MEDICAL, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/02/2006
Last Update Date: 12/30/2025
Certification Date: 12/30/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4107 HOHE ST
HOMER AK
99603-7008
US

IV. Provider business mailing address

4107 HOHE ST
HOMER AK
99603-7008
US

V. Phone/Fax

Practice location:
  • Phone: 907-226-3400
  • Fax: 907-226-3300
Mailing address:
  • Phone: 907-226-3400
  • Fax: 907-226-3300

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code332BP3500X
TaxonomyParenteral & Enteral Nutrition Supplies (DME)
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code332BX2000X
TaxonomyOxygen Equipment & Supplies (DME)
License Number991850
License Number StateAK

VIII. Authorized Official

Name: BERENICE I HALPIN
Title or Position: PARTNER
Credential:
Phone: 907-299-3500