Provider Demographics
NPI:1992127682
Name:ACACIARX
Entity type:Organization
Organization Name:ACACIARX
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:JUSTIN
Authorized Official - Middle Name:MATTHEW
Authorized Official - Last Name:BROCK
Authorized Official - Suffix:
Authorized Official - Credentials:PHARM D
Authorized Official - Phone:520-405-7651
Mailing Address - Street 1:1845 W ORANGE GROVE RD STE 115
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85704-1146
Mailing Address - Country:US
Mailing Address - Phone:520-670-0777
Mailing Address - Fax:520-488-2566
Practice Address - Street 1:1845 W ORANGE GROVE RD
Practice Address - Street 2:SUITE 115
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85704-1134
Practice Address - Country:US
Practice Address - Phone:520-670-0777
Practice Address - Fax:520-620-9738
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-14
Last Update Date:2022-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZY005818333600000X
3336C0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy