Provider Demographics
NPI:1073039061
Name:NEGRUSA, ALEX M
Entity Type:Individual
Prefix:
First Name:ALEX
Middle Name:M
Last Name:NEGRUSA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20475 N 89TH DR
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:AZ
Mailing Address - Zip Code:85382-6460
Mailing Address - Country:US
Mailing Address - Phone:602-481-4721
Mailing Address - Fax:
Practice Address - Street 1:280 N AVONDALE BLVD
Practice Address - Street 2:
Practice Address - City:AVONDALE
Practice Address - State:AZ
Practice Address - Zip Code:85323-6902
Practice Address - Country:US
Practice Address - Phone:623-882-2021
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-21
Last Update Date:2017-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZS0227983336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy