Provider Demographics
NPI:1053341966
Name:PROFESSIONAL HOME IV INC
Entity type:Organization
Organization Name:PROFESSIONAL HOME IV INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:KEVIN
Authorized Official - Last Name:HENDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:907-262-8737
Mailing Address - Street 1:182 S BIRCH ST
Mailing Address - Street 2:
Mailing Address - City:SOLDOTNA
Mailing Address - State:AK
Mailing Address - Zip Code:99669-8020
Mailing Address - Country:US
Mailing Address - Phone:907-262-8737
Mailing Address - Fax:907-260-7405
Practice Address - Street 1:182 S BIRCH ST
Practice Address - Street 2:
Practice Address - City:SOLDOTNA
Practice Address - State:AK
Practice Address - Zip Code:99669-8020
Practice Address - Country:US
Practice Address - Phone:907-262-8737
Practice Address - Fax:907-260-7405
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-04
Last Update Date:2022-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK4903336H0001X
AKPHAR4903336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336H0001XSuppliersPharmacyHome Infusion Therapy Pharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKPH0246Medicaid
AK1021642Medicaid
AKMS1723Medicaid
AK1028530Medicaid
AK1619615Medicaid
AKPH0246Medicaid