Provider Demographics
NPI:1730779745
Name:FORTIN, MARY K (CPHT)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:K
Last Name:FORTIN
Suffix:
Gender:F
Credentials:CPHT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3100 CHANNEL DR STE 300
Mailing Address - Street 2:
Mailing Address - City:JUNEAU
Mailing Address - State:AK
Mailing Address - Zip Code:99801-7837
Mailing Address - Country:US
Mailing Address - Phone:907-463-4031
Mailing Address - Fax:907-463-6658
Practice Address - Street 1:1200 SALMON CREEK LANE
Practice Address - Street 2:
Practice Address - City:JUNEAU
Practice Address - State:AK
Practice Address - Zip Code:99801
Practice Address - Country:US
Practice Address - Phone:907-463-4031
Practice Address - Fax:907-463-6658
Is Sole Proprietor?:No
Enumeration Date:2021-01-23
Last Update Date:2021-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AKPHAC169183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician