Provider Demographics
NPI:1083805261
Name:DOUGLAS PHARMACY LLC
Entity Type:Organization
Organization Name:DOUGLAS PHARMACY LLC
Other - Org Name:DOUGLAS HEALTH MART PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GREG
Authorized Official - Middle Name:
Authorized Official - Last Name:SHUMAKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:520-364-2315
Mailing Address - Street 1:PO BOX 597
Mailing Address - Street 2:
Mailing Address - City:SAINT DAVID
Mailing Address - State:AZ
Mailing Address - Zip Code:85630-0597
Mailing Address - Country:US
Mailing Address - Phone:520-240-3936
Mailing Address - Fax:520-720-4417
Practice Address - Street 1:94 W 5TH ST
Practice Address - Street 2:
Practice Address - City:DOUGLAS
Practice Address - State:AZ
Practice Address - Zip Code:85607-2851
Practice Address - Country:US
Practice Address - Phone:520-364-2315
Practice Address - Fax:520-364-2318
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-05
Last Update Date:2011-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZY0048783336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
0354895OtherNCPDP PROVIDER IDENTIFICATION NUMBER
AZ290702Medicaid