=====================================================
General NPI Number Information
=====================================================
NPI Number | 1174233696
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | STAR QUEZADA PHARM D
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/28/2022
-----------------------------------------------------
Last Update Date | 11/28/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 13723 N LITCHFIELD RD
-----------------------------------------------------
City | SURPRISE
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85379-4268
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 623-255-3208
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1711 N 159TH AVE UNIT 2022
-----------------------------------------------------
City | GOODYEAR
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85395-7187
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | S026230
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------