Provider Demographics
NPI:1164729828
Name:MD PHARMACY LLC
Entity Type:Organization
Organization Name:MD PHARMACY LLC
Other - Org Name:MD PHARMACY
Other - Org Type:Other Name
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:BOESEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:602-616-8831
Mailing Address - Street 1:17250 N. HARTFORD DR.
Mailing Address - Street 2:SUITE 115
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85255
Mailing Address - Country:US
Mailing Address - Phone:844-436-7928
Mailing Address - Fax:909-949-6331
Practice Address - Street 1:1601 MONTE VISTA AVE
Practice Address - Street 2:SUITE 130
Practice Address - City:CLAREMONT
Practice Address - State:CA
Practice Address - Zip Code:91711-2962
Practice Address - Country:US
Practice Address - Phone:909-949-6337
Practice Address - Fax:909-949-6331
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-02-16
Last Update Date:2016-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA505193336C0003X
CA552763336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy