Healthcare Provider Details

I. General information

NPI: 1003806050
Provider Name (Legal Business Name): APOTHECARY SHOP OF PHOENIX, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/21/2005
Last Update Date: 02/07/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1701 E THOMAS RD STE 203
PHOENIX AZ
85016-7674
US

IV. Provider business mailing address

1606 W WHISPERING WIND DR
PHOENIX AZ
85085-0678
US

V. Phone/Fax

Practice location:
  • Phone: 602-252-6120
  • Fax: 602-252-6127
Mailing address:
  • Phone: 623-434-3659
  • Fax: 623-434-3673

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License NumberY005087
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code3336S0011X
TaxonomySpecialty Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: JOHN MUSIL
Title or Position: DIRECTOR/CEO
Credential:
Phone: 623-434-3657