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General NPI Number Information
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NPI Number | 1447315494
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Entity Type | Organization
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Legal Business Name | SAGE MEMORIAL HOSPITAL
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Dates
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Enumeration Date | 12/27/2006
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Last Update Date | 06/09/2009
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Provider Practice Location Address
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Address Line | HWY 264 AND 191
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City | GANADO
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State | AZ
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Zip | 86505
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Country | US
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Telephone | 928-755-4500
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Fax | 928-755-4659
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Provider Business Mailing Address
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Address Line | PO BOX 457
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City | GANADO
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State | AZ
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Zip | 86505-0457
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | DIR OF PHCY
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Name | FARID KIYARASH
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Credential |
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Telephone | 928-755-4500
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 3336M0003X
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Taxonomy Name | Managed Care Organization Pharmacy
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 3336C0002X
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Taxonomy Name | Clinic Pharmacy
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License Number | Y000758
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License Number State | AZ
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