=====================================================
General NPI Number Information
=====================================================
NPI Number | 1154975043
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BETHANY HOME DISCOUNT PHARMACY LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/29/2019
-----------------------------------------------------
Last Update Date | 08/15/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6601 W BETHANY HOME RD STE A10
-----------------------------------------------------
City | GLENDALE
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85301-4946
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 623-440-7717
-----------------------------------------------------
Fax | 623-440-7781
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6601 W BETHANY HOME RD STE A10
-----------------------------------------------------
City | GLENDALE
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85301-4946
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 623-440-7717
-----------------------------------------------------
Fax | 623-440-7781
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MEMBER
-----------------------------------------------------
Name | SUSHMITHA GODISHALA
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 602-585-2901
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 333600000X
-----------------------------------------------------
Taxonomy Name | Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------