Basic Information
| Provider Information | |||||||||
| NPI: | 1093756884 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SMITHS FOOD & DRUG CENTERS INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | FRYS FOOD AND DRUG | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 500 S 99TH AVE | ||||||||
| Address2: | |||||||||
| City: | TOLLESON | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 853539700 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6239074933 | ||||||||
| FaxNumber: | 6239074990 | ||||||||
| Practice Location | |||||||||
| Address1: | 825 W UNIVERSITY DR | ||||||||
| Address2: | |||||||||
| City: | MESA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852015555 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4808447197 | ||||||||
| FaxNumber: | 4808444841 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/10/2006 | ||||||||
| LastUpdateDate: | 04/26/2012 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | LANGWORTHY | ||||||||
| AuthorizedOfficialFirstName: | KARLA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PHARMACY LICENSING MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 5136981878 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 333600000X | N | Suppliers | Pharmacy | 332B00000X | N | Suppliers | Durable Medical Equipment & Medical Supplies | 3336C0003X | Y003097 | AZ | Y | Suppliers | Pharmacy | Community/Retail Pharmacy |
ID Information
| ID | Type | State | Issuer | Description | 489121 | 05 | AZ | MEDICAID | 0313697 | 01 | NCPDP PROVIDER IDENTIFICATION NUMBER | OTHER |