Basic Information
| Provider Information | |||||||||
| NPI: | 1801900766 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | DHEW IND HLTH SV HLTH SVS & MNTL HLTH ADM | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | PIMC PHARMACY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 31001-0698 | ||||||||
| Address2: | |||||||||
| City: | PASADENA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 911100698 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6022631200 | ||||||||
| FaxNumber: | 6022631618 | ||||||||
| Practice Location | |||||||||
| Address1: | 4212 N 16TH ST | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850165319 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6022631200 | ||||||||
| FaxNumber: | 6022631618 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/18/2006 | ||||||||
| LastUpdateDate: | 06/18/2019 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | DICK | ||||||||
| AuthorizedOfficialFirstName: | DEANNA | ||||||||
| AuthorizedOfficialMiddleName: | J. | ||||||||
| AuthorizedOfficialTitleorPosition: | (CEO) CHIEF EXECUTIVE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 6022631567 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MISS | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MSW., MHA. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3336S0011X | N | Suppliers | Pharmacy | Specialty Pharmacy | 332800000X | AZS07912 | AZ | Y | Suppliers | Indian Health Service/Tribal/Urban Indian Health (I/T/U) Pharmacy |
ID Information
| ID | Type | State | Issuer | Description | 022062 | 05 | AZ | MEDICAID | 0324602 | 01 | NCPDP PROVIDER IDENTIFICATION NUMBER | OTHER |