Provider Demographics
NPI:1548455967
Name:SUSITNA MEDISET SERVICES INC
Entity type:Organization
Organization Name:SUSITNA MEDISET SERVICES INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:EXECT VP
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:
Authorized Official - Last Name:MUNDELL
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:907-373-7933
Mailing Address - Street 1:1751 E GARDNER WAY
Mailing Address - Street 2:STE F
Mailing Address - City:WASILLA
Mailing Address - State:AK
Mailing Address - Zip Code:99654-6564
Mailing Address - Country:US
Mailing Address - Phone:907-352-4306
Mailing Address - Fax:907-373-7939
Practice Address - Street 1:1751 E GARDNER WAY
Practice Address - Street 2:STE F
Practice Address - City:WASILLA
Practice Address - State:AK
Practice Address - Zip Code:99654-6564
Practice Address - Country:US
Practice Address - Phone:907-352-4306
Practice Address - Fax:907-357-7590
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-10
Last Update Date:2012-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3336C0003X
AK4383336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKPH0267Medicaid
0227810OtherNCPDP PROVIDER IDENTIFICATION NUMBER