Provider Demographics
NPI:1225201932
Name:MEDCO AT HOME LLC
Entity Type:Organization
Organization Name:MEDCO AT HOME LLC
Other - Org Name:MEDCO HEALTH SOLUTIONS OF SCOTTSDALE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SENIORDIRECTOR, LICENSING
Authorized Official - Prefix:
Authorized Official - First Name:LISA
Authorized Official - Middle Name:
Authorized Official - Last Name:CANNONE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:314-684-5075
Mailing Address - Street 1:14811 N KIERLAND BLVD
Mailing Address - Street 2:STE 100 RM 109
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85254-2729
Mailing Address - Country:US
Mailing Address - Phone:480-368-5005
Mailing Address - Fax:480-368-5040
Practice Address - Street 1:14811 N KIERLAND BLVD
Practice Address - Street 2:STE 100 RM 109
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85254-2729
Practice Address - Country:US
Practice Address - Phone:480-368-5005
Practice Address - Fax:480-368-5040
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-03
Last Update Date:2013-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3336C0003X
AZY0049243336M0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336M0002XSuppliersPharmacyMail Order Pharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
0355304OtherNCPDP PROVIDER IDENTIFICATION NUMBER