Provider Demographics
NPI:1710216544
Name:ALASKA ISLAND COMMUNITY SERVICES
Entity Type:Organization
Organization Name:ALASKA ISLAND COMMUNITY SERVICES
Other - Org Name:ALASKA ISLAND COMMUNITY SERVICES PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:WALKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:907-874-2373
Mailing Address - Street 1:PO BOX 1231
Mailing Address - Street 2:
Mailing Address - City:WRANGELL
Mailing Address - State:AK
Mailing Address - Zip Code:99929-1231
Mailing Address - Country:US
Mailing Address - Phone:907-874-5005
Mailing Address - Fax:907-874-4719
Practice Address - Street 1:333 CHURCH ST
Practice Address - Street 2:
Practice Address - City:WRANGELL
Practice Address - State:AK
Practice Address - Zip Code:99929
Practice Address - Country:US
Practice Address - Phone:907-874-5005
Practice Address - Fax:907-874-4719
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-12-07
Last Update Date:2017-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0003X, 3336C0003X
AK4713336C0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0002XSuppliersPharmacyClinic Pharmacy
No333600000XSuppliersPharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2122841OtherPK
2122841OtherPK