Healthcare Provider Details

I. General information

NPI: 1588592323
Provider Name (Legal Business Name): ELK RIDGE KINGMAN PHARMACY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/12/2026
Last Update Date: 05/12/2026
Certification Date: 05/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1510 N STOCKTON HILL RD
KINGMAN AZ
86401-5173
US

IV. Provider business mailing address

1510 N STOCKTON HILL RD
KINGMAN AZ
86401-5173
US

V. Phone/Fax

Practice location:
  • Phone: 928-718-4510
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: MELVA A GONZALEZ
Title or Position: PHARMACY COORDINATOR
Credential:
Phone: 520-670-3813