1255591418 NPI number — HAVASU HEALTH CARE PHARM

Table of content: (NPI 1255591418)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1255591418 NPI number — HAVASU HEALTH CARE PHARM

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
HAVASU HEALTH CARE PHARM
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:
Provider Other Organization Name Type Code:
6
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:
1255591418
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/11/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3560 CHALLENGER DR
Provider Second Line Business Mailing Address:
STE 106
Provider Business Mailing Address City Name:
LAKE HAVASU CITY
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
86406-9152
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3560 CHALLENGER DR
Provider Second Line Business Practice Location Address:
STE 106
Provider Business Practice Location Address City Name:
LAKE HAVASU CITY
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
86406-9152
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
928-855-9888
Provider Business Practice Location Address Fax Number:
928-855-9888
Provider Enumeration Date:
06/11/2008

Additional Information

Authorized Official

Authorized Official Last Name:
DAHLBERG
Authorized Official First Name:
KELLY
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
928-855-9888

Provider Taxonomy Codes

  • Taxonomy code: 3336M0003X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336L0003X , with the licence number: Y0004984 , 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: 0355366 . This is a "OTHER ID NUMBER" identifier . This identifiers is of the category "OTHER".




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