Provider Demographics
NPI:1376554949
Name:UPTOWN PHARMACY OF KINGMAN , INC
Entity Type:Organization
Organization Name:UPTOWN PHARMACY OF KINGMAN , INC
Other - Org Name:UPTOWN DRUG GOLDEN VALLEY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CHRIS
Authorized Official - Middle Name:HOWARD
Authorized Official - Last Name:PROFFIT
Authorized Official - Suffix:
Authorized Official - Credentials:BS PHARMACY
Authorized Official - Phone:928-565-3900
Mailing Address - Street 1:4263 US HIGHWAY 68
Mailing Address - Street 2:STE B
Mailing Address - City:GOLDEN VALLEY
Mailing Address - State:AZ
Mailing Address - Zip Code:86413-8569
Mailing Address - Country:US
Mailing Address - Phone:928-565-3900
Mailing Address - Fax:928-565-4004
Practice Address - Street 1:4263 US HIGHWAY 68
Practice Address - Street 2:STE B
Practice Address - City:GOLDEN VALLEY
Practice Address - State:AZ
Practice Address - Zip Code:86413-8569
Practice Address - Country:US
Practice Address - Phone:928-565-3900
Practice Address - Fax:928-565-4004
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-10
Last Update Date:2024-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
AZY0070483336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
1990529OtherPK
AZ235609Medicaid