Provider Demographics
NPI:1053031278
Name:MAILLE, JASON MARC (PHARMD)
Entity type:Individual
Prefix:
First Name:JASON
Middle Name:MARC
Last Name:MAILLE
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:PO BOX 962
Mailing Address - Street 2:
Mailing Address - City:KOTZEBUE
Mailing Address - State:AK
Mailing Address - Zip Code:99752-0962
Mailing Address - Country:US
Mailing Address - Phone:802-782-6852
Mailing Address - Fax:
Practice Address - Street 1:436 5TH AVENUE
Practice Address - Street 2:
Practice Address - City:KOTZEBUE
Practice Address - State:AK
Practice Address - Zip Code:99752
Practice Address - Country:US
Practice Address - Phone:907-442-7182
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-29
Last Update Date:2023-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT033.0134736183500000X
AK199982183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist