Provider Demographics
NPI:1104717297
Name:KOSYAK, ALEXANDR EUGENE
Entity type:Individual
Prefix:
First Name:ALEXANDR
Middle Name:EUGENE
Last Name:KOSYAK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:724 EDITH ST
Mailing Address - Street 2:
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59801-3908
Mailing Address - Country:US
Mailing Address - Phone:703-965-0054
Mailing Address - Fax:
Practice Address - Street 1:724 EDITH ST
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59801-3908
Practice Address - Country:US
Practice Address - Phone:703-965-0054
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-07-15
Last Update Date:2025-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT3001183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist