1902445802 NPI number — NORTHERN ARIZONA PHARMACY LLC

Table of content: (NPI 1902445802)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1902445802 NPI number — NORTHERN ARIZONA PHARMACY LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NORTHERN ARIZONA PHARMACY LLC
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:
DEWEY 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:
1902445802
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/08/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1932 N STATE ROUTE 89
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHINO VALLEY
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
86323-5643
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
928-515-0046
Provider Business Mailing Address Fax Number:
928-515-0047

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
12075 E STATE ROUTE 69
Provider Second Line Business Practice Location Address:
SUITE E
Provider Business Practice Location Address City Name:
DEWEY
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
86327
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
928-515-0455
Provider Business Practice Location Address Fax Number:
928-515-0456
Provider Enumeration Date:
12/26/2019

Additional Information

Authorized Official

Authorized Official Last Name:
DYKSTRA
Authorized Official First Name:
JASON
Authorized Official Middle Name:
JAMES
Authorized Official Title or Position:
MANAGER
Authorized Official Telephone Number:
928-515-0046

Provider Taxonomy Codes

  • Taxonomy code: 3336C0003X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 003672 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".




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