Healthcare Provider Details

I. General information

NPI: 1053824003
Provider Name (Legal Business Name): ALI LOIS ICENOGLE PHARMACIST
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/13/2017
Last Update Date: 09/29/2021
Certification Date: 09/29/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3601 S 6TH AVE
TUCSON AZ
85723-1532
US

IV. Provider business mailing address

2501 W ORANGE GROVE RD UNIT 66
TUCSON AZ
85741-3417
US

V. Phone/Fax

Practice location:
  • Phone: 520-792-1450
  • Fax:
Mailing address:
  • Phone: 480-789-9151
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberPH61056519
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: