Provider Demographics
NPI:1073069860
Name:BGH PHARMACY
Entity Type:Organization
Organization Name:BGH PHARMACY
Other - Org Name:BGH PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PIC/OWENR
Authorized Official - Prefix:
Authorized Official - First Name:APRIL
Authorized Official - Middle Name:
Authorized Official - Last Name:AL FATLAWI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:623-455-3368
Mailing Address - Street 1:3544 W GLENDALE AVE
Mailing Address - Street 2:SUITE E
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85051-8359
Mailing Address - Country:US
Mailing Address - Phone:623-455-3368
Mailing Address - Fax:623-243-5314
Practice Address - Street 1:3544 W GLENDALE AVE STE E
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85051-8359
Practice Address - Country:US
Practice Address - Phone:623-455-3368
Practice Address - Fax:623-243-5314
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-31
Last Update Date:2016-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZY006953333600000X
3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2166064OtherPK