Healthcare Provider Details

I. General information

NPI: 1073069860
Provider Name (Legal Business Name): BGH PHARMACY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/31/2016
Last Update Date: 11/08/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3544 W GLENDALE AVE STE E
PHOENIX AZ
85051-8359
US

IV. Provider business mailing address

3544 W GLENDALE AVE SUITE E
PHOENIX AZ
85051-8359
US

V. Phone/Fax

Practice location:
  • Phone: 623-455-3368
  • Fax: 623-243-5314
Mailing address:
  • Phone: 623-455-3368
  • Fax: 623-243-5314

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License NumberY006953
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: APRIL AL FATLAWI
Title or Position: PIC/OWENR
Credential:
Phone: 623-455-3368