Healthcare Provider Details

I. General information

NPI: 1053341966
Provider Name (Legal Business Name): PROFESSIONAL HOME IV INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/04/2006
Last Update Date: 09/27/2022
Certification Date: 09/27/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

182 S BIRCH ST
SOLDOTNA AK
99669-8020
US

IV. Provider business mailing address

182 S BIRCH ST
SOLDOTNA AK
99669-8020
US

V. Phone/Fax

Practice location:
  • Phone: 907-262-8737
  • Fax: 907-260-7405
Mailing address:
  • Phone: 907-262-8737
  • Fax: 907-260-7405

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336H0001X
TaxonomyHome Infusion Therapy Pharmacy
License Number490
License Number StateAK
# 2
Primary TaxonomyN
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License NumberPHAR490
License Number StateAK

VIII. Authorized Official

Name: JAMES KEVIN HENDERSON
Title or Position: OWNER
Credential: RPH
Phone: 907-262-8737