1386017564 NPI number — CASA GRANDE PHARMACY INC

Table of content: (NPI 1386017564)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1386017564 NPI number — CASA GRANDE PHARMACY INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CASA GRANDE PHARMACY 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:
GRAND 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:
1386017564
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/11/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1659 E FLORENCE BLVD STE 7
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CASA GRANDE
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85122-4785
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
520-518-5720
Provider Business Mailing Address Fax Number:
480-371-2757

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1659 E FLORENCE BLVD STE 7
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CASA GRANDE
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85122-4785
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
520-518-5720
Provider Business Practice Location Address Fax Number:
480-371-2757
Provider Enumeration Date:
11/10/2015

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
ELMISSIREY
Authorized Official First Name:
MOHAMED ESLAM
Authorized Official Middle Name:
Authorized Official Title or Position:
OFFICER,PIC,AO
Authorized Official Telephone Number:
480-444-6612

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 333600000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0003X , with the licence number: Y006618 , registered in the state of AZ ; 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" .

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

  • Identifier: 083433 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2155127 . This is a "PK" identifier . This identifiers is of the category "OTHER".