Provider Demographics
NPI:1366717860
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
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 1:2580 HIGHWAY 95 STE 106
Practice Address - Street 2:
Practice Address - City:BULLHEAD CITY
Practice Address - State:AZ
Practice Address - Zip Code:86442-7324
Practice Address - Country:US
Practice Address - Phone:928-219-5912
Practice Address - Fax:928-219-5915
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-03-15
Last Update Date:2012-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3336C0004X, 333600000X
AZY0054783336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ697715Medicaid
0357447OtherNCPDP PROVIDER IDENTIFICATION NUMBER