Healthcare Provider Details

I. General information

NPI: 1225792989
Provider Name (Legal Business Name): MARCUS ALLEN WILLINGHAM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/28/2021
Last Update Date: 10/28/2021
Certification Date: 10/28/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

554 W BASELINE RD
MESA AZ
85210-6019
US

IV. Provider business mailing address

2352 W ALTA VISTA RD
PHOENIX AZ
85041-5326
US

V. Phone/Fax

Practice location:
  • Phone: 480-969-6234
  • Fax:
Mailing address:
  • Phone: 619-288-0671
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberS025534
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code1835P2201X
TaxonomyAmbulatory Care Pharmacist
License NumberS025534
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: