=====================================================
General NPI Number Information
=====================================================
NPI Number | 1982823712
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PRIMARY HEALTH-SMMPP, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/24/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10860 N MAVINEE DR
-----------------------------------------------------
City | ORO VALLEY
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85737-9526
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 520-297-3800
-----------------------------------------------------
Fax | 520-297-3466
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10860 N MAVINEE DR
-----------------------------------------------------
City | ORO VALLEY
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85737-9526
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 520-297-3800
-----------------------------------------------------
Fax | 520-297-3466
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO PRESIDENT
-----------------------------------------------------
Name | JERALD R CACCIATORE
-----------------------------------------------------
Credential | R PH
-----------------------------------------------------
Telephone | 520-297-3800
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | 6870
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------