Provider Demographics
NPI:1467441808
Name:SUSITNA PROFESSIONAL PHARMACY
Entity Type:Organization
Organization Name:SUSITNA PROFESSIONAL PHARMACY
Other - Org Name:SUSITNA PROFESSIONAL PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE VP
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:
Authorized Official - Last Name:MUNDELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:907-373-7933
Mailing Address - Street 1:1751 E GARDNER WAY
Mailing Address - Street 2:STE G
Mailing Address - City:WASILLA
Mailing Address - State:AK
Mailing Address - Zip Code:99654-6564
Mailing Address - Country:US
Mailing Address - Phone:907-373-7933
Mailing Address - Fax:907-373-7939
Practice Address - Street 1:1751 E GARDNER WAY
Practice Address - Street 2:STE G
Practice Address - City:WASILLA
Practice Address - State:AK
Practice Address - Zip Code:99654-6564
Practice Address - Country:US
Practice Address - Phone:907-373-7933
Practice Address - Fax:907-373-7939
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-18
Last Update Date:2012-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336M0002X, 3336S0011X
AK4083336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336M0002XSuppliersPharmacyMail Order Pharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKPH0266Medicaid
0202553OtherNCPDP PROVIDER IDENTIFICATION NUMBER