Provider Demographics
NPI:1467958611
Name:ARIZONA COMMUNITY PHARMACY
Entity Type:Organization
Organization Name:ARIZONA COMMUNITY PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:YULIYA
Authorized Official - Middle Name:K
Authorized Official - Last Name:ILYUSHENKO
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:323-704-5369
Mailing Address - Street 1:14100 N 83RD AVE STE 160
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:AZ
Mailing Address - Zip Code:85381-5653
Mailing Address - Country:US
Mailing Address - Phone:623-230-3194
Mailing Address - Fax:623-233-1610
Practice Address - Street 1:14100 N 83RD AVE STE 160
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:AZ
Practice Address - Zip Code:85381
Practice Address - Country:US
Practice Address - Phone:623-230-3194
Practice Address - Fax:623-233-1610
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-04-04
Last Update Date:2019-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZY007643333600000X
AZ3336C0003X, 3336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No333600000XSuppliersPharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ431832Medicaid