Provider Demographics
NPI:1467630012
Name:MOUNTAIN PARK HEALTH CENTER
Entity Type:Organization
Organization Name:MOUNTAIN PARK HEALTH CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ASSOCIATE PHARMACY DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:
Authorized Official - Last Name:SOTO
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:602-586-3026
Mailing Address - Street 1:3003 N CENTRAL AVE STE 1600
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85012-2908
Mailing Address - Country:US
Mailing Address - Phone:602-323-3242
Mailing Address - Fax:602-323-3496
Practice Address - Street 1:635 E BASELINE RD
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85042-6551
Practice Address - Country:US
Practice Address - Phone:602-323-3435
Practice Address - Fax:602-305-8590
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MOUNTAIN PARK HEALTH CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-02-06
Last Update Date:2019-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ32543336C0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0002XSuppliersPharmacyClinic Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ3254OtherBOARD OF PHARMACY
AZ530073Medicaid