Healthcare Provider Details

I. General information

NPI: 1447315494
Provider Name (Legal Business Name): SAGE MEMORIAL HOSPITAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/27/2006
Last Update Date: 06/09/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

HWY 264 AND 191
GANADO AZ
86505
US

IV. Provider business mailing address

PO BOX 457
GANADO AZ
86505-0457
US

V. Phone/Fax

Practice location:
  • Phone: 928-755-4500
  • Fax: 928-755-4659
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0002X
TaxonomyClinic Pharmacy
License NumberY000758
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code3336M0003X
TaxonomyManaged Care Organization Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: FARID KIYARASH
Title or Position: DIR OF PHCY
Credential:
Phone: 928-755-4500