MEDICARE: BASELINE 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	333600000X	Pharmacy	Y005528	AZ

General Provider Information

NPI Number	:	1558619023
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BASELINE PHARMACY

Provider Business Mailing Address
First Line	:	303 E BASELINE RD STE 103
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85042-6561
Country	:	US
Telephone Number	:	602-903-7228
Fax Number	:

Provider Business Practice Location Address
First Line	:	303 E BASELINE RD STE 103
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85042-6561
Country	:	US
Telephone Number	:	602-903-7228
Fax Number	:

Authorized Official
Title or Position	:	PIC
Name	:	DR. VILAWOE A. BOADU
Credential	:	PHARMD
Telephone Number	:	602-903-7228

Provider Enumeration Date	:	08/15/2012
Last Update Date	:	08/15/2012

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