Provider Demographics
NPI:1386655959
Name:GOLDSTEIN PHARMACEUTICALS SERVICES INC
Entity Type:Organization
Organization Name:GOLDSTEIN PHARMACEUTICALS SERVICES INC
Other - Org Name:MACK'S PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LARRY
Authorized Official - Middle Name:
Authorized Official - Last Name:GOLDSTEIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:602-956-8540
Mailing Address - Street 1:PO BOX 80555
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85060-0555
Mailing Address - Country:US
Mailing Address - Phone:602-956-8540
Mailing Address - Fax:602-956-5423
Practice Address - Street 1:3628 E THOMAS RD
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85018-7502
Practice Address - Country:US
Practice Address - Phone:602-956-8540
Practice Address - Fax:602-957-0291
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-10
Last Update Date:2011-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
AZY0021073336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
0305993OtherNCPDP PROVIDER IDENTIFICATION NUMBER
AZ300567Medicaid