Healthcare Provider Details

I. General information

NPI: 1285645853
Provider Name (Legal Business Name): PAYSON APOTHECARY PHARMACY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/10/2006
Last Update Date: 12/13/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 W MAIN ST SUITE D
PAYSON AZ
85541-5441
US

IV. Provider business mailing address

201 W MAIN ST SUITE D
PAYSON AZ
85541-5441
US

V. Phone/Fax

Practice location:
  • Phone: 928-468-8299
  • Fax: 928-468-8322
Mailing address:
  • Phone: 928-468-8299
  • Fax: 928-468-8322

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License NumberY004258
License Number StateAZ

VIII. Authorized Official

Name: CRAIG MATHEWS
Title or Position: OWNER
Credential:
Phone: 928-468-8299