Basic Information
| Provider Information | |||||||||
| NPI: | 1730121302 | ||||||||
| 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: | 4949 W RAY RD | ||||||||
| Address2: | |||||||||
| City: | CHANDLER | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852262064 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4809407797 | ||||||||
| FaxNumber: | 4807055193 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/11/2006 | ||||||||
| LastUpdateDate: | 04/07/2014 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | LANGWORTHY | ||||||||
| AuthorizedOfficialFirstName: | KARLA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | MANAGER OF PHARMACY CREDENTIALING | ||||||||
| AuthorizedOfficialTelephone: | 5136981878 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 333600000X | N | Suppliers | Pharmacy | 332B00000X | N | Suppliers | Durable Medical Equipment & Medical Supplies | 3336C0003X | Y003081 | AZ | Y | Suppliers | Pharmacy | Community/Retail Pharmacy |
ID Information
| ID | Type | State | Issuer | Description | 494617 | 05 | AZ | MEDICAID | 1989709 | 01 | PK | OTHER |