Provider Demographics
NPI:1235580697
Name:LUMICERA HEALTH SERVICES LLC
Entity Type:Organization
Organization Name:LUMICERA HEALTH SERVICES LLC
Other - Org Name:LUMICERA HEALTH SERVICES, LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACIST IN CHARGE
Authorized Official - Prefix:
Authorized Official - First Name:PETER
Authorized Official - Middle Name:
Authorized Official - Last Name:NIELSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:608-310-1837
Mailing Address - Street 1:5350 E HIGH ST
Mailing Address - Street 2:SUITE 200
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85054-5465
Mailing Address - Country:US
Mailing Address - Phone:855-847-3553
Mailing Address - Fax:855-847-3558
Practice Address - Street 1:5350 E HIGH ST STE 200
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85054-5500
Practice Address - Country:US
Practice Address - Phone:855-847-3553
Practice Address - Fax:855-847-3558
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-06-28
Last Update Date:2023-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
AZY0068073336S0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336S0011XSuppliersPharmacySpecialty Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2160812OtherPK