Provider Demographics
NPI:1487244323
Name:PALOVERDE HEALTH SERVICES PHARMACY LLC
Entity type:Organization
Organization Name:PALOVERDE HEALTH SERVICES PHARMACY LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/PIC
Authorized Official - Prefix:
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:EDWARD
Authorized Official - Last Name:PAULL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:928-485-4315
Mailing Address - Street 1:PO BOX 9
Mailing Address - Street 2:
Mailing Address - City:PIMA
Mailing Address - State:AZ
Mailing Address - Zip Code:85543-0009
Mailing Address - Country:US
Mailing Address - Phone:928-485-4315
Mailing Address - Fax:
Practice Address - Street 1:18 W CENTER ST
Practice Address - Street 2:
Practice Address - City:PIMA
Practice Address - State:AZ
Practice Address - Zip Code:85543-0030
Practice Address - Country:US
Practice Address - Phone:928-322-6009
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-01-25
Last Update Date:2022-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy SpecialistGroup - Single Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Single Specialty
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ097392Medicaid