Healthcare Provider Details

I. General information

NPI: 1215705447
Provider Name (Legal Business Name): FAIRVIEW PRODUCE PHARMACY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/18/2023
Last Update Date: 12/18/2023
Certification Date: 12/18/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2555 W FAIRVIEW ST STE 104
CHANDLER AZ
85224-4708
US

IV. Provider business mailing address

7600 N 16TH ST STE 100
PHOENIX AZ
85020-4446
US

V. Phone/Fax

Practice location:
  • Phone: 480-550-7948
  • Fax:
Mailing address:
  • Phone: 602-430-2738
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: BRETT BANNISTER
Title or Position: CEO
Credential:
Phone: 602-430-2738