1275990640 NPI number — MR. JUSTIN RUSSELL DOROTHEO PHARMD

Table of content: MR. JUSTIN RUSSELL DOROTHEO PHARMD (NPI 1275990640)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1275990640 NPI number — MR. JUSTIN RUSSELL DOROTHEO PHARMD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DOROTHEO
Provider First Name:
JUSTIN
Provider Middle Name:
RUSSELL
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
PHARMD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
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:
1275990640
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/12/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3167 N KYLE LOOP
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FLAGSTAFF
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
86004-1837
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
561-715-4749
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
WINSLOW INDIAN HEALTHCARE CENTER (PHARMACY DEPT.)
Provider Second Line Business Practice Location Address:
500 INDIANA AVE
Provider Business Practice Location Address City Name:
WINSLOW
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
86047-7403
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
928-289-6215
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/15/2016

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 183500000X , with the licence number:  PS55417 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 183500000X , with the licence number: PSI29655 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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