Healthcare Provider Details

I. General information

NPI: 1376251371
Provider Name (Legal Business Name): MIND 247 PRACTICE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/08/2022
Last Update Date: 11/08/2022
Certification Date: 11/08/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2728 N 24TH ST
PHOENIX AZ
85008-1050
US

IV. Provider business mailing address

1465 N SCOTTSDALE RD STE 400
SCOTTSDALE AZ
85257-3634
US

V. Phone/Fax

Practice location:
  • Phone: 844-646-3247
  • Fax: 480-546-4048
Mailing address:
  • Phone: 844-646-3247
  • Fax: 480-546-4048

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code3336C0002X
TaxonomyClinic Pharmacy
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3336I0012X
TaxonomyInstitutional Pharmacy
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code3336S0011X
TaxonomySpecialty Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: AISHA LYNN DEPRIEST
Title or Position: DIRECTOR OF CREDENTIALING
Credential:
Phone: 844-646-3247