=====================================================
General NPI Number Information
=====================================================
NPI Number | 1487958583
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ARIZONA PHARMACY, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/04/2011
-----------------------------------------------------
Last Update Date | 01/04/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 19636 N 27TH AVE SUITE 104
-----------------------------------------------------
City | PHOENIX
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85027-4013
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 623-939-1120
-----------------------------------------------------
Fax | 623-939-1130
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 20118 N 67TH AVE SUITE 300-181
-----------------------------------------------------
City | GLENDALE
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85308-4621
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 618-960-7173
-----------------------------------------------------
Fax | 623-939-1130
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PHARMACY MANAGER
-----------------------------------------------------
Name | DR. GRACE LINGAD JONES
-----------------------------------------------------
Credential | PHARM.D.
-----------------------------------------------------
Telephone | 618-960-7173
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number | Y005320
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------