Healthcare Provider Details

I. General information

NPI: 1124307541
Provider Name (Legal Business Name): RICHARD FENDORAK PHARMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/16/2011
Last Update Date: 08/16/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6690 W UNION HILLS DR
GLENDALE AZ
85308-1011
US

IV. Provider business mailing address

5324 E WASHINGTON ST BUILDING A
PHOENIX AZ
85034-2144
US

V. Phone/Fax

Practice location:
  • Phone: 623-561-5319
  • Fax: 623-561-6683
Mailing address:
  • Phone: 602-732-3384
  • Fax: 602-732-3394

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberS018610
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: