Healthcare Provider Details

I. General information

NPI: 1528880069
Provider Name (Legal Business Name): ZACHARY DECONO CPHT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/28/2024
Last Update Date: 10/28/2024
Certification Date: 10/27/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6644 E BAYWOOD AVE
MESA AZ
85206-1747
US

IV. Provider business mailing address

8723 E FOX ST
MESA AZ
85207-5013
US

V. Phone/Fax

Practice location:
  • Phone: 480-321-2222
  • Fax:
Mailing address:
  • Phone: 480-796-9670
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number1215327598
License Number StateAZ

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: