Basic Information
| Provider Information | |||||||||
| NPI: | 1710216544 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ALASKA ISLAND COMMUNITY SERVICES | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | ALASKA ISLAND COMMUNITY SERVICES PHARMACY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1231 | ||||||||
| Address2: | |||||||||
| City: | WRANGELL | ||||||||
| State: | AK | ||||||||
| PostalCode: | 999291231 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9078745005 | ||||||||
| FaxNumber: | 9078744719 | ||||||||
| Practice Location | |||||||||
| Address1: | 333 CHURCH ST | ||||||||
| Address2: | |||||||||
| City: | WRANGELL | ||||||||
| State: | AK | ||||||||
| PostalCode: | 99929 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9078745005 | ||||||||
| FaxNumber: | 9078744719 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/07/2009 | ||||||||
| LastUpdateDate: | 03/15/2017 | ||||||||
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| AuthorizedOfficialLastName: | WALKER | ||||||||
| AuthorizedOfficialFirstName: | MARK | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 9078742373 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 333600000X | N | Suppliers | Pharmacy | 3336C0003X | N | Suppliers | Pharmacy | Community/Retail Pharmacy | 3336C0002X | 471 | AK | Y | Suppliers | Pharmacy | Clinic Pharmacy |
ID Information
| ID | Type | State | Issuer | Description | 2122841 | 01 | PK | OTHER |