MEDICARE: NORTH COUNTRY HEALTHCARE, 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	3336C0002X	Clinic Pharmacy	3287	AZ

General Provider Information

NPI Number	:	1649334442
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NORTH COUNTRY HEALTHCARE, INC.

Provider Business Mailing Address
First Line	:	2920 NORTH 4TH STREET
Second Line	:
City	:	FLAGSTAFF
State	:	AZ
Zip	:	86004
Country	:	US
Telephone Number	:	928-213-0589
Fax Number	:	928-213-0597

Provider Business Practice Location Address
First Line	:	2920 NORTH 4TH STREET
Second Line	:
City	:	FLAGSTAFF
State	:	AZ
Zip	:	86004
Country	:	US
Telephone Number	:	928-213-0589
Fax Number	:	928-213-0597

Authorized Official
Title or Position	:	CEO
Name	:	ANN M ROGGENBUCK
Credential	:
Telephone Number	:	928-774-8325

Provider Enumeration Date	:	12/19/2006
Last Update Date	:	03/07/2023

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