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General NPI Number Information
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NPI Number | 1053341966
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Entity Type | Organization
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Legal Business Name | PROFESSIONAL HOME IV INC
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Dates
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Enumeration Date | 07/04/2006
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Last Update Date | 09/27/2022
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Provider Practice Location Address
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Address Line | 182 S BIRCH ST
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City | SOLDOTNA
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State | AK
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Zip | 99669-8020
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Country | US
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Telephone | 907-262-8737
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Fax | 907-260-7405
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Provider Business Mailing Address
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Address Line | 182 S BIRCH ST
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City | SOLDOTNA
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State | AK
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Zip | 99669-8020
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Country | US
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Telephone | 907-262-8737
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Fax | 907-260-7405
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Authorized Official
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Title or Position | OWNER
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Name | JAMES KEVIN HENDERSON
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Credential | RPH
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Telephone | 907-262-8737
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 3336L0003X
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Taxonomy Name | Long Term Care Pharmacy
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License Number | PHAR490
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License Number State | AK
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Taxonomy #2
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Taxonomy Code | 3336H0001X
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Taxonomy Name | Home Infusion Therapy Pharmacy
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License Number | 490
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License Number State | AK
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