Provider Demographics
NPI:1417192980
Name:STATE OF NEVADA
Entity Type:Organization
Organization Name:STATE OF NEVADA
Other - Org Name:SOUTHERN NEVADA ADULT MENTAL HEALTH PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:STATEWIDE PHARMACY DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:
Authorized Official - Last Name:COSTAS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:702-486-6301
Mailing Address - Street 1:1590 W SUNSET RD
Mailing Address - Street 2:
Mailing Address - City:HENDERSON
Mailing Address - State:NV
Mailing Address - Zip Code:89014-6633
Mailing Address - Country:US
Mailing Address - Phone:702-486-6860
Mailing Address - Fax:702-486-6862
Practice Address - Street 1:1590 W SUNSET RD
Practice Address - Street 2:
Practice Address - City:HENDERSON
Practice Address - State:NV
Practice Address - Zip Code:89014-6633
Practice Address - Country:US
Practice Address - Phone:702-486-6860
Practice Address - Fax:702-486-6862
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-11
Last Update Date:2016-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVPH011803336C0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0002XSuppliersPharmacyClinic Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2052188OtherPK