1154584977 NPI number — MARANA HEALTH CENTER INC

Table of content: (NPI 1154584977)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1154584977 NPI number — MARANA HEALTH CENTER INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MARANA HEALTH CENTER INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
CLINICA DEL ALMA PHARMACY
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1154584977
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/04/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 188
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MARANA
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85653-0188
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
520-682-4111
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3690 S PARK AVE STE 805
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TUCSON
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85713-5042
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
520-616-6778
Provider Business Practice Location Address Fax Number:
520-882-0697
Provider Enumeration Date:
07/02/2008

Additional Information

Authorized Official

Authorized Official Last Name:
KUNTZ
Authorized Official First Name:
CLINTON
Authorized Official Middle Name:
G
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
520-682-4111

Provider Taxonomy Codes

  • Taxonomy code: 333600000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0002X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 3336C0003X , with the licence number: Y004885 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 369853 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".
  • Identifier: 329592 . This is a "GROUP MEDICAID" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".




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