Provider Demographics
NPI:1508004144
Name:DESERT SKY PHARMACY, LLC
Entity Type:Organization
Organization Name:DESERT SKY PHARMACY, LLC
Other - Org Name:DESERT SKY PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER-PHARMACIST IN CHARGE
Authorized Official - Prefix:
Authorized Official - First Name:TAI
Authorized Official - Middle Name:
Authorized Official - Last Name:PHAM
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMACIST
Authorized Official - Phone:623-209-0870
Mailing Address - Street 1:6750 W THUNDERBIRD RD STE 103
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:AZ
Mailing Address - Zip Code:85381-5046
Mailing Address - Country:US
Mailing Address - Phone:623-209-0870
Mailing Address - Fax:623-209-0872
Practice Address - Street 1:6750 W THUNDERBIRD RD STE 103
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:AZ
Practice Address - Zip Code:85381-5046
Practice Address - Country:US
Practice Address - Phone:623-209-0870
Practice Address - Fax:623-209-0872
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-02-03
Last Update Date:2017-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
AZY0051033336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2118934OtherPK
AZ408470Medicaid