MEDICARE: UPTOWN PHARMACY OF KINGMAN , INC

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	333600000X	Pharmacy
2	3336C0003X	Community/Retail Pharmacy	Y007048	AZ

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1990529	OTHER		PK
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1376554949
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	UPTOWN PHARMACY OF KINGMAN , INC

Provider Business Mailing Address
First Line	:	4263 US HIGHWAY 68
Second Line	:	STE B
City	:	GOLDEN VALLEY
State	:	AZ
Zip	:	86413-8569
Country	:	US
Telephone Number	:	928-565-3900
Fax Number	:	928-565-4004

Provider Business Practice Location Address
First Line	:	4263 US HIGHWAY 68
Second Line	:	STE B
City	:	GOLDEN VALLEY
State	:	AZ
Zip	:	86413-8569
Country	:	US
Telephone Number	:	928-565-3900
Fax Number	:	928-565-4004

Authorized Official
Title or Position	:	OWNER
Name	:	CHRIS HOWARD PROFFIT
Credential	:	B.S. PHARMACY
Telephone Number	:	928-565-3900

Provider Enumeration Date	:	08/10/2006
Last Update Date	:	04/11/2024

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