Susitna Professional Pharmacy

Primary specialty

Community/Retail PharmacyTaxonomy code 3336C0003X

License

408 Issued in AK

Legal business name

SUSITNA PROFESSIONAL PHARMACY

Doing business as

Susitna Professional Pharmacy

Practice address

1751 E Gardner Way
Ste G
Wasilla, AK 99654-6564

Phone

(907) 373-7933

Fax

(907) 373-7939

NPI assigned

Oct 18, 2005

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Mary Mundell

Title

Executive VP

Phone

(907) 373-7933

Specialties & licenses 4

Addresses

Other identifiers 2

Other names 1

• SUSITNA PROFESSIONAL PHARMACY Doing business as

Locations

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1129593600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1343260800000",
    "number": "1467441808",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1751 E GARDNER WAY",
            "address_2": "STE G",
            "city": "WASILLA",
            "state": "AK",
            "postal_code": "996546564",
            "telephone_number": "907-373-7933",
            "fax_number": "907-373-7939"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1751 E GARDNER WAY",
            "address_2": "STE G",
            "city": "WASILLA",
            "state": "AK",
            "postal_code": "996546564",
            "telephone_number": "907-373-7933",
            "fax_number": "907-373-7939"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "SUSITNA PROFESSIONAL PHARMACY",
        "organizational_subpart": "NO",
        "enumeration_date": "2005-10-18",
        "last_updated": "2012-07-26",
        "status": "A",
        "authorized_official_last_name": "MUNDELL",
        "authorized_official_first_name": "MARY",
        "authorized_official_title_or_position": "EXECUTIVE VP",
        "authorized_official_telephone_number": "907-373-7933"
    },
    "taxonomies": [
        {
            "code": "333600000X",
            "taxonomy_group": "",
            "desc": "Pharmacy",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "3336C0003X",
            "taxonomy_group": "",
            "desc": "Pharmacy, Community/Retail Pharmacy",
            "state": "AK",
            "license": "408",
            "primary": true
        },
        {
            "code": "3336M0002X",
            "taxonomy_group": "",
            "desc": "Pharmacy, Mail Order Pharmacy",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "3336S0011X",
            "taxonomy_group": "",
            "desc": "Pharmacy, Specialty Pharmacy",
            "state": null,
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "PH0266",
            "state": "AK"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "NCPDP PROVIDER IDENTIFICATION NUMBER",
            "identifier": "0202553",
            "state": null
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "SUSITNA PROFESSIONAL PHARMACY",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

• Surgery Center of Wasilla, LLC
• Surgical Specialists of Alaska LLC
• Susan K Miller
• Susan Reed
• Susitna Mediset Services Inc (Susitna Mediset Services)
• Callum Patrick Sutherland, DPT
• Jolene Grace Sutherland, RN CASE MANAGER
• Melanie Sutherland, LMT
• Brian Corey Swain
• Monique Swan

• Community/Retail Pharmacy in Wasilla, AK
• Providers in Wasilla, AK by specialty
• Community/Retail Pharmacy in Alaska

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 26, 2012; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.