Provider Demographics
NPI:1003806050
Name:APOTHECARY SHOP OF PHOENIX, INC
Entity Type:Organization
Organization Name:APOTHECARY SHOP OF PHOENIX, INC
Other - Org Name:APOTHECARY SHOP OF PHOENIX, INC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR/CEO
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:MUSIL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:623-434-3657
Mailing Address - Street 1:1606 W WHISPERING WIND DR
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85085-0678
Mailing Address - Country:US
Mailing Address - Phone:623-434-3659
Mailing Address - Fax:623-434-3673
Practice Address - Street 1:1701 E THOMAS RD STE 203
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85016-7674
Practice Address - Country:US
Practice Address - Phone:602-252-6120
Practice Address - Fax:602-252-6127
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-21
Last Update Date:2011-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZY0050873336C0003X
3336C0004X, 3336S0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ474601Medicaid
0320212OtherNCPDP PROVIDER IDENTIFICATION NUMBER
0320212OtherNCPDP PROVIDER IDENTIFICATION NUMBER