Provider Demographics
NPI:1184842718
Name:HARBOR VISTA
Entity Type:Organization
Organization Name:HARBOR VISTA
Other - Org Name:HARBOR VISTA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:BPHARM
Authorized Official - Prefix:
Authorized Official - First Name:FEMI
Authorized Official - Middle Name:
Authorized Official - Last Name:OMODARA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:602-277-5444
Mailing Address - Street 1:PO BOX 5693
Mailing Address - Street 2:
Mailing Address - City:GOODYEAR
Mailing Address - State:AZ
Mailing Address - Zip Code:85338-0612
Mailing Address - Country:US
Mailing Address - Phone:602-277-5444
Mailing Address - Fax:
Practice Address - Street 1:9133 W THUNDERBIRD
Practice Address - Street 2:#102
Practice Address - City:PEORIA
Practice Address - State:AZ
Practice Address - Zip Code:85381
Practice Address - Country:US
Practice Address - Phone:602-277-5444
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-20
Last Update Date:2009-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ43183336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ6174880001Medicare NSC