Healthcare Provider Details

I. General information

NPI: 1619208535
Provider Name (Legal Business Name): MARK POWELL PHARMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/15/2010
Last Update Date: 07/31/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4302 W BUCKEYE RD
PHOENIX AZ
85043
US

IV. Provider business mailing address

6690 W UNION HILLS DR
GLENDALE AZ
85308-1011
US

V. Phone/Fax

Practice location:
  • Phone: 602-477-5198
  • Fax:
Mailing address:
  • Phone: 623-561-5319
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License Number051.291885
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberS017032
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: