Healthcare Provider Details

I. General information

NPI: 1164404828
Provider Name (Legal Business Name): PORTABLE MEDICAL PHARMACY- ARIZONA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/17/2005
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6150 E GRANT RD
TUCSON AZ
85712-5801
US

IV. Provider business mailing address

6150 E GRANT RD
TUCSON AZ
85712-5801
US

V. Phone/Fax

Practice location:
  • Phone: 520-296-0317
  • Fax:
Mailing address:
  • Phone: 520-296-0317
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License Number4292
License Number StateAZ

VIII. Authorized Official

Name: MRS. ROBBIE D WILLIAMS
Title or Position: DIRECTOR OF CORPORATE SERVICES
Credential:
Phone: 702-939-6559