Healthcare Provider Details

I. General information

NPI: 1699298257
Provider Name (Legal Business Name): AUSTIN VANHORN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/25/2017
Last Update Date: 07/25/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

PO BOX 600
TUBA CITY AZ
86045-0600
US

IV. Provider business mailing address

3850 N FANNING DR UNIT F2
FLAGSTAFF AZ
86004-2288
US

V. Phone/Fax

Practice location:
  • Phone: 928-289-2759
  • Fax: 928-283-2758
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberRP450511
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: