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NPI Code Detail

MEDICARE: STATE OF ARIZONA

MEDICARE: STATE OF ARIZONA
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
1333600000XPharmacy
23336I0012XInstitutional PharmacyY000486AZ

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
11988000OTHERPK

General Provider Information

NPI Number : 1538170162
Entity Type Code : Organization
Provider Name (Legal Business Name) : STATE OF ARIZONA
Provider Business Mailing Address
First Line : 2500 E VAN BUREN ST
Second Line :
City : PHOENIX
State : AZ
Zip : 85008-6037
Country : US
Telephone Number : 602-220-6060
Fax Number : 602-220-6194
Provider Business Practice Location Address
First Line : 2500 E VAN BUREN ST
Second Line :
City : PHOENIX
State : AZ
Zip : 85008-6037
Country : US
Telephone Number : 602-220-6060
Fax Number : 602-220-6194
Authorized Official
Title or Position : DOP
Name : KELLY HOLLADAY
Credential : PHARMD
Telephone Number : 602-220-6060
Provider Enumeration Date : 08/10/2006
Last Update Date : 07/19/2018

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Directions to “STATE OF ARIZONA ” Practice Location

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