Provider Demographics
NPI:1154493666
Name:MANIILAQ HEALTH CENTER PHARMACY
Entity type:Organization
Organization Name:MANIILAQ HEALTH CENTER PHARMACY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHRM CHIEF
Authorized Official - Prefix:
Authorized Official - First Name:FREDDY
Authorized Official - Middle Name:
Authorized Official - Last Name:KANIKI
Authorized Official - Suffix:
Authorized Official - Credentials:PHRMD
Authorized Official - Phone:907-442-7336
Mailing Address - Street 1:PO BOX 43
Mailing Address - Street 2:
Mailing Address - City:KOTZEBUE
Mailing Address - State:AK
Mailing Address - Zip Code:99752-0043
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5TH ST AND GRIZZLEY
Practice Address - Street 2:
Practice Address - City:KOTZEBUE
Practice Address - State:AK
Practice Address - Zip Code:99752
Practice Address - Country:US
Practice Address - Phone:907-442-7182
Practice Address - Fax:907-442-7309
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-14
Last Update Date:2016-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332800000XSuppliersIndian Health Service/Tribal/Urban Indian Health (I/T/U) Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKHS190PMedicaid
1996986OtherPK