Healthcare Provider Details

I. General information

NPI: 1396244976
Provider Name (Legal Business Name): REMGBEKOR
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/08/2018
Last Update Date: 07/19/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7227 S CENTRAL AVE STE 1080
PHOENIX AZ
85042-5457
US

IV. Provider business mailing address

PO BOX 5693
GOODYEAR AZ
85338-0612
US

V. Phone/Fax

Practice location:
  • Phone: 602-441-3564
  • Fax: 602-441-4838
Mailing address:
  • Phone: 602-441-3564
  • Fax: 602-441-4838

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code332800000X
TaxonomyIndian Health Service/Tribal/Urban Indian Health (I/T/U) Pharmacy
License Number
License Number StateNULL
# 3
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License NumberY007459
License Number StateAZ
# 4
Primary TaxonomyN
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number
License Number StateNULL
# 5
Primary TaxonomyN
Taxonomy Code3336S0011X
TaxonomySpecialty Pharmacy
License Number
License Number StateNULL
# 6
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number
License Number StateNULL

VIII. Authorized Official

Name: OLUFEMI OMODARA
Title or Position: OWNER
Credential:
Phone: 602-441-3564