MEDICARE: ELK RIDGE KINGMAN PHARMACY

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	3336C0002X	Clinic Pharmacy

General Provider Information

NPI Number	:	1275480923
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ELK RIDGE KINGMAN PHARMACY

Provider Business Mailing Address
First Line	:	1510 N STOCKTON HILL RD
Second Line	:
City	:	KINGMAN
State	:	AZ
Zip	:	86401-5173
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1510 N STOCKTON HILL RD
Second Line	:
City	:	KINGMAN
State	:	AZ
Zip	:	86401-5173
Country	:	US
Telephone Number	:	520-670-3909
Fax Number	:

Authorized Official
Title or Position	:	PHARMACY COORDINATOR
Name	:	MELVA A GONZALEZ
Credential	:
Telephone Number	:	520-670-3813

Provider Enumeration Date	:	03/12/2026
Last Update Date	:	03/12/2026

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