Healthcare Provider Details

I. General information

NPI: 1346679875
Provider Name (Legal Business Name): THREE BEARS ALASKA, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/05/2013
Last Update Date: 02/25/2022
Certification Date: 02/25/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3950 S KNIK GOOSE BAY RD
WASILLA AK
99623-5008
US

IV. Provider business mailing address

7362 W PARKS HWY # 814
WASILLA AK
99623-9300
US

V. Phone/Fax

Practice location:
  • Phone: 907-376-4511
  • Fax: 907-376-4591
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number489
License Number StateAK

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier1601591
Identifier TypeMEDICAID
Identifier StateAK
Identifier Issuer

VIII. Authorized Official

Name: DAVID WEISZ
Title or Position: PRESIDENT
Credential:
Phone: 907-357-4311