Provider Demographics
NPI:1194175588
Name:NORTHERN ARIZONA PHARMACY LLC
Entity type:Organization
Organization Name:NORTHERN ARIZONA PHARMACY LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JASON
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:DYKSTRA
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:928-515-0046
Mailing Address - Street 1:1932 N STATE ROUTE 89
Mailing Address - Street 2:
Mailing Address - City:CHINO VALLEY
Mailing Address - State:AZ
Mailing Address - Zip Code:86323-5643
Mailing Address - Country:US
Mailing Address - Phone:928-515-0046
Mailing Address - Fax:928-515-0047
Practice Address - Street 1:1932 N STATE ROUTE 89
Practice Address - Street 2:
Practice Address - City:CHINO VALLEY
Practice Address - State:AZ
Practice Address - Zip Code:86323-5643
Practice Address - Country:US
Practice Address - Phone:928-515-0046
Practice Address - Fax:928-515-0047
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-06-15
Last Update Date:2019-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZY006900333600000X
3336C0003X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ171606Medicaid
2160678OtherPK