Provider Demographics
NPI:1063825222
Name:EZYFAST PHARMACY L L C
Entity type:Organization
Organization Name:EZYFAST PHARMACY L L C
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:EZEKIEL
Authorized Official - Middle Name:
Authorized Official - Last Name:KESITILWE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:928-230-9812
Mailing Address - Street 1:PO BOX 21238
Mailing Address - Street 2:
Mailing Address - City:BULLHEAD CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:86439-1238
Mailing Address - Country:US
Mailing Address - Phone:928-219-5912
Mailing Address - Fax:928-219-5915
Practice Address - Street 1:1701 S CASINO DR
Practice Address - Street 2:
Practice Address - City:LAUGHLIN
Practice Address - State:NV
Practice Address - Zip Code:89029-1503
Practice Address - Country:US
Practice Address - Phone:702-298-1701
Practice Address - Fax:702-298-1705
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-06-05
Last Update Date:2017-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336L0003X
NVPH032363336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2148529OtherPK
NV1063825222Medicaid