=====================================================
General NPI Number Information
=====================================================
NPI Number | 1114922861
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | APOTHECARY SHOP OF PAYSON
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/19/2005
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 201 W MAIN ST STE L
-----------------------------------------------------
City | PAYSON
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85541-5442
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 928-468-8299
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9777 N 91ST ST STE C103
-----------------------------------------------------
City | SCOTTSDALE
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85258-5087
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | JOHN MUSIL
-----------------------------------------------------
Credential | PHARMD
-----------------------------------------------------
Telephone | 480-451-3771
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 333600000X
-----------------------------------------------------
Taxonomy Name | Pharmacy
-----------------------------------------------------
License Number | YO3386
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------