Provider Demographics
NPI:1992197362
Name:PROFITT, JUSTIN ELLIOT (PHARM D)
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:ELLIOT
Last Name:PROFITT
Suffix:
Gender:M
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2521 E MOUNTAIN VILLAGE DR
Mailing Address - Street 2:STE B 431
Mailing Address - City:WASILLA
Mailing Address - State:AK
Mailing Address - Zip Code:99654-7373
Mailing Address - Country:US
Mailing Address - Phone:907-232-0835
Mailing Address - Fax:
Practice Address - Street 1:1350 S SEWARD MERIDIAN PKWY
Practice Address - Street 2:
Practice Address - City:WASILLA
Practice Address - State:AK
Practice Address - Zip Code:99654-8332
Practice Address - Country:US
Practice Address - Phone:907-376-9783
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-02-23
Last Update Date:2015-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK2286183500000X
MT7485183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist