Healthcare Provider Details

I. General information

NPI: 1740484989
Provider Name (Legal Business Name): MANIILAQ ASSOCIATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/12/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

436 5TH & TED STEVENS WAY
KOTZEBUE AK
99752
US

IV. Provider business mailing address

PO BOX 43
KOTZEBUE AK
99752-0043
US

V. Phone/Fax

Practice location:
  • Phone: 907-442-3321
  • Fax: 907-442-7250
Mailing address:
  • Phone: 907-442-3321
  • Fax: 907-442-7250

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0002X
TaxonomyClinic Pharmacy
License Number234051
License Number StateAK

VIII. Authorized Official

Name: PAUL HANSON
Title or Position: ADMINISTRATOR
Credential:
Phone: 970-442-3321