Healthcare Provider Details

I. General information

NPI: 1861815144
Provider Name (Legal Business Name): DIMITRIY YUKHANOV
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/22/2014
Last Update Date: 12/16/2025
Certification Date: 12/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5050 W BASELINE RD
LAVEEN AZ
85339-7324
US

IV. Provider business mailing address

230 W ANGELA DR
PHOENIX AZ
85023-6568
US

V. Phone/Fax

Practice location:
  • Phone: 602-703-8555
  • Fax:
Mailing address:
  • Phone: 602-703-8555
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberS019846
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: