1639100803 NPI number — APOTHECARY SHOP OF SANDY INC

Table of content: (NPI 1639100803)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1639100803 NPI number — APOTHECARY SHOP OF SANDY INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
APOTHECARY SHOP OF SANDY 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:
SOUTHWOOD APOTHECARY SHOP
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:
1639100803
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/06/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1606 W WHISPERING WIND DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PHOENIX
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85085-0678
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
623-434-3659
Provider Business Mailing Address Fax Number:
623-434-3673

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
880 E 9400 S
Provider Second Line Business Practice Location Address:
STE 118
Provider Business Practice Location Address City Name:
SANDY
Provider Business Practice Location Address State Name:
UT
Provider Business Practice Location Address Postal Code:
84094-3667
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
801-571-0340
Provider Business Practice Location Address Fax Number:
801-576-8938
Provider Enumeration Date:
07/06/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
DOWNHOUR
Authorized Official First Name:
NATHAN
Authorized Official Middle Name:
Authorized Official Title or Position:
VP OF OPERATIONS
Authorized Official Telephone Number:
623-434-3654

Provider Taxonomy Codes

  • Taxonomy code: 3336C0003X , with the licence number:  69707811703 , registered in the state of UT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 3336C0004X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336S0011X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 4603165 . This is a "NCPDP PROVIDER IDENTIFICATION NUMBER" identifier . This identifiers is of the category "OTHER".
  • Identifier: 67629 . This is a "MEDICARE - MASS IMMUNIZATION ROSTER BILLER" identifier . This identifiers is of the category "OTHER".
  • Identifier: 8703064560008 , issued by the state of ( UT ) . This identifiers is of the category "MEDICAID".