Healthcare Provider Details

I. General information

NPI: 1366717860
Provider Name (Legal Business Name): EZYFAST PHARMACY L L C
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/15/2012
Last Update Date: 05/22/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2580 HIGHWAY 95 STE 106
BULLHEAD CITY AZ
86442-7324
US

IV. Provider business mailing address

PO BOX 21238
BULLHEAD CITY AZ
86439-1238
US

V. Phone/Fax

Practice location:
  • Phone: 928-219-5912
  • Fax: 928-219-5915
Mailing address:
  • Phone: 928-219-5912
  • Fax: 928-219-5915

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License NumberY005478
License Number StateAZ
# 3
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: EZEKIEL KESITILWE
Title or Position: OWNER
Credential:
Phone: 928-230-9812