Provider Demographics
NPI:1184271660
Name:RALSTON, MADELYN
Entity type:Individual
Prefix:
First Name:MADELYN
Middle Name:
Last Name:RALSTON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6581 KARA SUE LOOP
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99504-4883
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:595 E PARKS HWY
Practice Address - Street 2:
Practice Address - City:WASILLA
Practice Address - State:AK
Practice Address - Zip Code:99654-8150
Practice Address - Country:US
Practice Address - Phone:907-352-1160
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-20
Last Update Date:2019-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK1457963336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy