Provider Demographics
NPI:1285458075
Name:DISTANTE, MICHAEL PAUL (PHARMD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:PAUL
Last Name:DISTANTE
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:215 GLENN ABBEY PL
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99504-4892
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7701 DEBARR RD STE A
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99504-1869
Practice Address - Country:US
Practice Address - Phone:907-269-1733
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-11-09
Last Update Date:2024-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK228690183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist