Provider Demographics
NPI:1003973041
Name:KODIAK AREA NATIVE ASSOCIATION PHARMACY
Entity Type:Organization
Organization Name:KODIAK AREA NATIVE ASSOCIATION PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:PFEFFER
Authorized Official - Suffix:
Authorized Official - Credentials:CEO
Authorized Official - Phone:907-486-9801
Mailing Address - Street 1:3449 E REZANOF DR
Mailing Address - Street 2:
Mailing Address - City:KODIAK
Mailing Address - State:AK
Mailing Address - Zip Code:99615-6952
Mailing Address - Country:US
Mailing Address - Phone:907-486-9860
Mailing Address - Fax:907-486-9895
Practice Address - Street 1:3449 E REZANOF DR
Practice Address - Street 2:
Practice Address - City:KODIAK
Practice Address - State:AK
Practice Address - Zip Code:99615-6952
Practice Address - Country:US
Practice Address - Phone:907-486-9860
Practice Address - Fax:907-486-9895
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-02
Last Update Date:2023-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK107332800000X, 332800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes332800000XSuppliersIndian Health Service/Tribal/Urban Indian Health (I/T/U) PharmacyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK1028490Medicaid
AK107OtherSTATE PHARMACY LICENSE #
0201347OtherNCPDP NUMBER
0201347OtherNCPDP NUMBER