Healthcare Provider Details

I. General information

NPI: 1053031278
Provider Name (Legal Business Name): JASON MARC MAILLE PHARMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/29/2022
Last Update Date: 01/04/2023
Certification Date: 01/04/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

436 5TH AVENUE
KOTZEBUE AK
99752
US

IV. Provider business mailing address

PO BOX 962
KOTZEBUE AK
99752-0962
US

V. Phone/Fax

Practice location:
  • Phone: 907-442-7182
  • Fax:
Mailing address:
  • Phone: 802-782-6852
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License Number033.0134736
License Number StateVT
# 2
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number199982
License Number StateAK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: