Provider Demographics
NPI:1003500158
Name:JOSEPHINE PHARMACY, LLC
Entity Type:Organization
Organization Name:JOSEPHINE PHARMACY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:OBIAGELI
Authorized Official - Middle Name:LISA
Authorized Official - Last Name:MOMODU
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:702-480-6221
Mailing Address - Street 1:6013 COTTONTAIL COVE ST
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89130-1352
Mailing Address - Country:US
Mailing Address - Phone:702-480-6221
Mailing Address - Fax:
Practice Address - Street 1:2013 E CHARLESTON BLVD
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89104-2056
Practice Address - Country:US
Practice Address - Phone:702-403-1118
Practice Address - Fax:702-403-1108
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-06-02
Last Update Date:2023-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV250026014Medicaid