Healthcare Provider Details

I. General information

NPI: 1912936956
Provider Name (Legal Business Name): CARR-GOTTSTEIN FOODS CO
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/02/2006
Last Update Date: 03/04/2020
Certification Date: 03/04/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

90 STERLING HWY
HOMER AK
99603-7439
US

IV. Provider business mailing address

250 E PARKCENTER BLVD
BOISE ID
83706-3940
US

V. Phone/Fax

Practice location:
  • Phone: 907-226-1060
  • Fax: 907-235-7245
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number401
License Number StateAK
# 2
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: KATHY GIANNAKOPOULOS
Title or Position: ENROLLMENTS MANAGER
Credential:
Phone: 208-395-3954