Healthcare Provider Details

I. General information

NPI: 1093135691
Provider Name (Legal Business Name): CVS/PHARMACY #9293
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/22/2014
Last Update Date: 04/22/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

325 W APACHE TRL
APACHE JUNCTION AZ
85120-3954
US

IV. Provider business mailing address

1848 S POWER RD APT 2323
MESS AZ
85206
US

V. Phone/Fax

Practice location:
  • Phone: 480-973-1129
  • Fax: 480-983-1547
Mailing address:
  • Phone: 270-480-3066
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License NumberS019677
License Number StateAZ

VIII. Authorized Official

Name: MR. DAVID CRENSHAW SMITH
Title or Position: STAFF PHARMACIST
Credential: R.PH.
Phone: 480-983-1129