Healthcare Provider Details

I. General information

NPI: 1467441808
Provider Name (Legal Business Name): SUSITNA PROFESSIONAL PHARMACY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/18/2005
Last Update Date: 07/26/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1751 E GARDNER WAY STE G
WASILLA AK
99654-6564
US

IV. Provider business mailing address

1751 E GARDNER WAY STE G
WASILLA AK
99654-6564
US

V. Phone/Fax

Practice location:
  • Phone: 907-373-7933
  • Fax: 907-373-7939
Mailing address:
  • Phone: 907-373-7933
  • Fax: 907-373-7939

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number408
License Number StateAK
# 3
Primary TaxonomyN
Taxonomy Code3336M0002X
TaxonomyMail Order Pharmacy
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code3336S0011X
TaxonomySpecialty Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: MARY MUNDELL
Title or Position: EXECUTIVE VP
Credential:
Phone: 907-373-7933