Healthcare Provider Details

I. General information

NPI: 1144723495
Provider Name (Legal Business Name): MARICOPA COUNTY D.B.A. MARICOPA COUNTY DEPART
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/13/2018
Last Update Date: 03/13/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1645 E ROOSEVELT ST
PHOENIX AZ
85006-3638
US

IV. Provider business mailing address

1645 E ROOSEVELT ST
PHOENIX AZ
85006-3638
US

V. Phone/Fax

Practice location:
  • Phone: 602-372-2544
  • Fax: 602-372-0342
Mailing address:
  • Phone: 602-372-2544
  • Fax: 602-372-0342

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835P0018X
TaxonomyPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
License NumberS022396
License Number StateAZ

VIII. Authorized Official

Name: DIANE DEJONGE-RYAN
Title or Position: PROGRAM MANAGER
Credential: MA
Phone: 602-372-2544