Provider Demographics
NPI:1093820011
Name:CAMELBACK VILLAGE PHARMACY INC
Entity type:Organization
Organization Name:CAMELBACK VILLAGE PHARMACY INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DENNIS
Authorized Official - Middle Name:
Authorized Official - Last Name:MEYERS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:602-840-1111
Mailing Address - Street 1:4416 E CAMELBACK RD
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85018-2824
Mailing Address - Country:US
Mailing Address - Phone:602-840-1111
Mailing Address - Fax:602-840-0111
Practice Address - Street 1:4416 E CAMELBACK RD
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85018-2824
Practice Address - Country:US
Practice Address - Phone:602-955-2880
Practice Address - Fax:602-956-3784
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-20
Last Update Date:2016-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
AZY023073336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
0313825OtherNCPDP PROVIDER IDENTIFICATION NUMBER
AZ242066Medicaid