Provider Demographics
NPI:1750415295
Name:PETERSBURG REXALL DRUG INC
Entity type:Organization
Organization Name:PETERSBURG REXALL DRUG INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:STORE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CATHERINE
Authorized Official - Middle Name:
Authorized Official - Last Name:KOWALSKI
Authorized Official - Suffix:
Authorized Official - Credentials:RPL
Authorized Official - Phone:907-772-3265
Mailing Address - Street 1:PO BOX 1209
Mailing Address - Street 2:
Mailing Address - City:PETERSBURG
Mailing Address - State:AK
Mailing Address - Zip Code:99833-1209
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:215 N NORDIC DR
Practice Address - Street 2:
Practice Address - City:PETERSBURG
Practice Address - State:AK
Practice Address - Zip Code:99833-1208
Practice Address - Country:US
Practice Address - Phone:907-772-3265
Practice Address - Fax:907-772-3165
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-15
Last Update Date:2016-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X, 3336C0004X, 3336L0003X
AKPHAR463336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
1996439OtherPK
AKDH0046Medicaid
AKDH0046Medicaid