1205871522 NPI number — MARICOPA COUNTY SPECIAL HEALTH CARE DISTRICT

Table of content: (NPI 1205871522)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1205871522 NPI number — MARICOPA COUNTY SPECIAL HEALTH CARE DISTRICT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MARICOPA COUNTY SPECIAL HEALTH CARE DISTRICT
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:
VALLEYWISE COMPREHENSIVE HEALTH CENTER - PHOENIX 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:
1205871522
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/24/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2525 E ROOSEVELT ST
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:
85008-4948
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
602-344-1064
Provider Business Mailing Address Fax Number:
602-344-1066

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2525 E ROOSEVELT ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PHOENIX
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85008-4948
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
602-344-1064
Provider Business Practice Location Address Fax Number:
602-344-1066
Provider Enumeration Date:
06/19/2006

Additional Information

Authorized Official

Authorized Official Last Name:
SOGARD
Authorized Official First Name:
ANNA
Authorized Official Middle Name:
Authorized Official Title or Position:
DIRECTOR OF PHARMACY
Authorized Official Telephone Number:
602-344-5253

Provider Taxonomy Codes

  • Taxonomy code: 333600000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0003X , with the licence number: Y004181 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1989614 . This is a "PK" identifier . This identifiers is of the category "OTHER".
  • Identifier: 161232 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".




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