Provider Demographics
NPI:1215080502
Name:DOWNTOWN DRUGSTORE
Entity type:Organization
Organization Name:DOWNTOWN DRUGSTORE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST OWNER
Authorized Official - Prefix:
Authorized Official - First Name:VASSA
Authorized Official - Middle Name:A
Authorized Official - Last Name:ROBERTSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:907-225-3144
Mailing Address - Street 1:300 FRONT ST
Mailing Address - Street 2:
Mailing Address - City:KETCHIKAN
Mailing Address - State:AK
Mailing Address - Zip Code:99901-6418
Mailing Address - Country:US
Mailing Address - Phone:907-225-3144
Mailing Address - Fax:907-247-3144
Practice Address - Street 1:300 FRONT ST
Practice Address - Street 2:
Practice Address - City:KETCHIKAN
Practice Address - State:AK
Practice Address - Zip Code:99901-6418
Practice Address - Country:US
Practice Address - Phone:907-225-3144
Practice Address - Fax:907-247-3144
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-19
Last Update Date:2008-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK2133336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKPH1252Medicaid
AKPH1252Medicaid