Healthcare Provider Details

I. General information

NPI: 1396524716
Provider Name (Legal Business Name): KATHRYN BAKER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/25/2023
Last Update Date: 09/25/2023
Certification Date: 09/25/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9069 W THUNDERBIRD RD
PEORIA AZ
85381-4412
US

IV. Provider business mailing address

9069 W THUNDERBIRD RD
PEORIA AZ
85381-4412
US

V. Phone/Fax

Practice location:
  • Phone: 623-876-2165
  • Fax:
Mailing address:
  • Phone: 623-876-2165
  • Fax: 623-876-2398

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberS008857
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: