=====================================================
General NPI Number Information
=====================================================
NPI Number | 1811468804
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SUMMIT HEALTHCARE ASSOCIATION
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/17/2018
-----------------------------------------------------
Last Update Date | 07/19/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4951 SOUTH WHITE MOUNTAIN ROAD, BLDG A., SUITE 1500
-----------------------------------------------------
City | SHOW LOW
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85901
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 928-537-6336
-----------------------------------------------------
Fax | 928-532-3506
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2200 E. SHOW LOW LAKE ROAD
-----------------------------------------------------
City | SHOW LOW
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85901
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 928-537-6321
-----------------------------------------------------
Fax | 928-537-7814
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CHIEF NURSING OFFICER
-----------------------------------------------------
Name | CAROLYN B JACOBS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 928-537-6932
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------