Provider Demographics
NPI:1982625943
Name:LAKE OTIS PHARMACY INC
Entity Type:Organization
Organization Name:LAKE OTIS PHARMACY INC
Other - Org Name:LAKE OTIS PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:WESLEY
Authorized Official - Middle Name:
Authorized Official - Last Name:SUTTERLIN
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:907-563-7878
Mailing Address - Street 1:4201 LAKE OTIS PKWY
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99508-5214
Mailing Address - Country:US
Mailing Address - Phone:907-563-7878
Mailing Address - Fax:907-563-7879
Practice Address - Street 1:4201 LAKE OTIS PKWY
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99508-5214
Practice Address - Country:US
Practice Address - Phone:907-563-7878
Practice Address - Fax:907-563-7879
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-22
Last Update Date:2012-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X, 3336C0004X
AK1633336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKPH0163Medicaid
0201525OtherNCPDP PROVIDER IDENTIFICATION NUMBER