Provider Demographics
NPI:1124570569
Name:DE LA HUERTA, ANNA
Entity Type:Individual
Prefix:
First Name:ANNA
Middle Name:
Last Name:DE LA HUERTA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 W THOMAS RD
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85013-4224
Mailing Address - Country:US
Mailing Address - Phone:602-406-3970
Mailing Address - Fax:602-406-7145
Practice Address - Street 1:500 W THOMAS RD
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85013-4224
Practice Address - Country:US
Practice Address - Phone:602-406-3970
Practice Address - Fax:602-406-7145
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-02
Last Update Date:2016-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZS011630183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist