1548767650 NPI number — KING TUT PHARMACY LLC

Table of content: (NPI 1548767650)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1548767650 NPI number — KING TUT PHARMACY LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
KING TUT 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:
KING TUT 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:
1548767650
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/27/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
90 E 3RD ST
Provider Second Line Business Mailing Address:
SUITE B
Provider Business Mailing Address City Name:
DOUGLAS
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85607-3154
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
520-364-6304
Provider Business Mailing Address Fax Number:
520-634-1157

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
90 E 3RD ST
Provider Second Line Business Practice Location Address:
SUITE B
Provider Business Practice Location Address City Name:
DOUGLAS
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85607-3154
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
520-364-6304
Provider Business Practice Location Address Fax Number:
520-634-1157
Provider Enumeration Date:
04/06/2018

Additional Information

Authorized Official

Authorized Official Last Name:
ISMAIL
Authorized Official First Name:
KARIEM
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER/PIC/AO
Authorized Official Telephone Number:
520-220-1281

Provider Taxonomy Codes

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

  • Identifier: 2176895 . This is a "PK" identifier . This identifiers is of the category "OTHER".




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