Provider Demographics
NPI:1316997083
Name:AVONDALE NEIGHBORHOOD PHARMACY LLC
Entity type:Organization
Organization Name:AVONDALE NEIGHBORHOOD PHARMACY LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LAMECK
Authorized Official - Middle Name:
Authorized Official - Last Name:NYAKWEBA
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:602-430-9646
Mailing Address - Street 1:10750 W MCDOWELL RD
Mailing Address - Street 2:BLDG. A STE. 110
Mailing Address - City:AVONDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85392-5960
Mailing Address - Country:US
Mailing Address - Phone:623-932-9800
Mailing Address - Fax:623-932-9817
Practice Address - Street 1:10750 W MCDOWELL RD
Practice Address - Street 2:BLDG. A STE. 110
Practice Address - City:AVONDALE
Practice Address - State:AZ
Practice Address - Zip Code:85392-5960
Practice Address - Country:US
Practice Address - Phone:623-932-9800
Practice Address - Fax:623-932-9817
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-11
Last Update Date:2010-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3336C0004X, 332B00000X
AZY0044483336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
0353398OtherNCPDP PROVIDER IDENTIFICATION NUMBER
AZ113658Medicaid