Provider Demographics
NPI:1114424199
Name:PHARMACY ONE LLC
Entity Type:Organization
Organization Name:PHARMACY ONE LLC
Other - Org Name:GOLD CANYON PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RANDAL
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:480-370-6892
Mailing Address - Street 1:6832 S KINGS RANCH RD STE 2
Mailing Address - Street 2:
Mailing Address - City:GOLD CANYON
Mailing Address - State:AZ
Mailing Address - Zip Code:85118-2929
Mailing Address - Country:US
Mailing Address - Phone:480-370-6892
Mailing Address - Fax:602-266-8275
Practice Address - Street 1:6832 S KINGS RANCH RD STE 2
Practice Address - Street 2:
Practice Address - City:GOLD CANYON
Practice Address - State:AZ
Practice Address - Zip Code:85118-2929
Practice Address - Country:US
Practice Address - Phone:480-288-8078
Practice Address - Fax:480-288-8076
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-04-06
Last Update Date:2018-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
AZY0075693336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2177102OtherPK