Healthcare Provider Details

I. General information

NPI: 1194175588
Provider Name (Legal Business Name): NORTHERN ARIZONA PHARMACY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/15/2016
Last Update Date: 12/20/2019
Certification Date: 12/20/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1932 N STATE ROUTE 89
CHINO VALLEY AZ
86323-5643
US

IV. Provider business mailing address

1932 N STATE ROUTE 89
CHINO VALLEY AZ
86323-5643
US

V. Phone/Fax

Practice location:
  • Phone: 928-515-0046
  • Fax: 928-515-0047
Mailing address:
  • Phone: 928-515-0046
  • Fax: 928-515-0047

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License NumberY006900
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: DR. JASON JAMES DYKSTRA
Title or Position: PHARMACIST
Credential: PHARMD
Phone: 928-515-0046