Provider Demographics
NPI:1487118402
Name:EKSTEDT, LEDJHA
Entity type:Individual
Prefix:
First Name:LEDJHA
Middle Name:
Last Name:EKSTEDT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4101 ARCTIC BLVD STE B
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99503-5702
Mailing Address - Country:US
Mailing Address - Phone:907-770-6081
Mailing Address - Fax:
Practice Address - Street 1:4101 ARCTIC BLVD STE B
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99503-5702
Practice Address - Country:US
Practice Address - Phone:907-770-6081
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-23
Last Update Date:2019-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AKPHAR4983336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK1619401Medicaid