Basic Information
Provider Information | |||||||||
NPI: | 1386686814 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | SMITHS FOOD & DRUG CENTERS INC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | FRYS FOOD AND DRUG | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 500 S 99TH AVE | ||||||||
Address2: |   | ||||||||
City: | TOLLESON | ||||||||
State: | AZ | ||||||||
PostalCode: | 853539700 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6239074933 | ||||||||
FaxNumber: | 6239074990 | ||||||||
Practice Location | |||||||||
Address1: | 390 N LITCHFIELD RD | ||||||||
Address2: |   | ||||||||
City: | GOODYEAR | ||||||||
State: | AZ | ||||||||
PostalCode: | 853381224 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6239250233 | ||||||||
FaxNumber: | 6239252352 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/11/2006 | ||||||||
LastUpdateDate: | 04/26/2012 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | LANGWORTHY | ||||||||
AuthorizedOfficialFirstName: | KARLA | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | PHARMACY LICENSING MANAGER | ||||||||
AuthorizedOfficialTelephone: | 5136981878 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332B00000X |   |   | N |   | Suppliers | Durable Medical Equipment & Medical Supplies |   | 333600000X |   |   | N |   | Suppliers | Pharmacy |   | 3336C0003X | Y003104 | AZ | Y |   | Suppliers | Pharmacy | Community/Retail Pharmacy |
ID Information
ID | Type | State | Issuer | Description | 0316477 | 01 |   | NCPDP PROVIDER IDENTIFICATION NUMBER | OTHER | 489204 | 05 | AZ |   | MEDICAID |