Healthcare Provider Details

I. General information

NPI: 1912918590
Provider Name (Legal Business Name): KINGMAN HOMETOWN PHARMACY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/10/2006
Last Update Date: 07/21/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2370 NORTHERN AVE STE A
KINGMAN AZ
86409-2573
US

IV. Provider business mailing address

2370 NORTHERN AVE STE A
KINGMAN AZ
86409-2573
US

V. Phone/Fax

Practice location:
  • Phone: 928-681-4888
  • Fax: 928-681-4534
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License Number4304
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: JENNIFER VELEZ
Title or Position: MGR
Credential:
Phone: 928-681-4888