Organization
SUSITNA PROFESSIONAL PHARMACY
Active
Other names
SUSITNA PROFESSIONAL PHARMACY
Organization subpart
No
Provider details
NPI number
Authorized official
MARY MUNDELL (EXECUTIVE VP)
(907) 373-7933
Entity
Organization
Contact information
Practice address
1751 E GARDNER WAY, STE G, WASILLA, AK 99654-6564
(907) 373-7933
(907) 373-7939
Mailing address
1751 E GARDNER WAY, STE G, WASILLA, AK 99654-6564
(907) 373-7933
(907) 373-7939
Taxonomy
Speciality
Code
Description
License number
State
333600000X
Pharmacy
—
—
3336C0003X
Community/Retail Pharmacy
Primary
408
AK
3336M0002X
Mail Order Pharmacy
—
—
3336S0011X
Specialty Pharmacy
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
0202553
NCPDP PROVIDER IDENTIFICATION NUMBER
—
05
—
PH0266
—
AK
Enumeration date
10/18/2005
Last updated
07/26/2012
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