Healthcare Provider Details

I. General information

NPI: 1447255187
Provider Name (Legal Business Name): APOTHECARY SHOP OF MESA INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/17/2005
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1432 S DOBSON RD STE 101
MESA AZ
85202-4769
US

IV. Provider business mailing address

23620 N 20TH DR STE 12
PHOENIX AZ
85085-0621
US

V. Phone/Fax

Practice location:
  • Phone: 480-969-9595
  • Fax: 480-969-9494
Mailing address:
  • Phone: 623-434-3650
  • Fax: 623-434-3676

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License Number4155
License Number StateAZ

VIII. Authorized Official

Name: JOHN MUSIL
Title or Position: CEO
Credential: PHARMD
Phone: 623-434-3650