Provider Demographics
NPI:1396244976
Name:REMGBEKOR
Entity type:Organization
Organization Name:REMGBEKOR
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:OLUFEMI
Authorized Official - Middle Name:
Authorized Official - Last Name:OMODARA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:602-441-3564
Mailing Address - Street 1:PO BOX 5693
Mailing Address - Street 2:
Mailing Address - City:GOODYEAR
Mailing Address - State:AZ
Mailing Address - Zip Code:85338-0612
Mailing Address - Country:US
Mailing Address - Phone:602-441-3564
Mailing Address - Fax:602-441-4838
Practice Address - Street 1:7227 S CENTRAL AVE STE 1080
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85042-5457
Practice Address - Country:US
Practice Address - Phone:602-441-3564
Practice Address - Fax:602-441-4838
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-02-08
Last Update Date:2018-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332800000X, 333600000X, 3336C0004X, 3336L0003X, 3336S0011X
AZY0074593336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332800000XSuppliersIndian Health Service/Tribal/Urban Indian Health (I/T/U) PharmacyGroup - Single Specialty
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2176046OtherPK
AZ365183Medicaid