Provider Demographics
NPI:1548767650
Name:KING TUT PHARMACY LLC
Entity Type:Organization
Organization Name:KING TUT PHARMACY LLC
Other - Org Name:KING TUT PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/PIC/AO
Authorized Official - Prefix:
Authorized Official - First Name:KARIEM
Authorized Official - Middle Name:
Authorized Official - Last Name:ISMAIL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:520-220-1281
Mailing Address - Street 1:90 E 3RD ST
Mailing Address - Street 2:SUITE B
Mailing Address - City:DOUGLAS
Mailing Address - State:AZ
Mailing Address - Zip Code:85607-3154
Mailing Address - Country:US
Mailing Address - Phone:520-364-6304
Mailing Address - Fax:520-634-1157
Practice Address - Street 1:90 E 3RD ST
Practice Address - Street 2:SUITE B
Practice Address - City:DOUGLAS
Practice Address - State:AZ
Practice Address - Zip Code:85607-3154
Practice Address - Country:US
Practice Address - Phone:520-364-6304
Practice Address - Fax:520-634-1157
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-04-06
Last Update Date:2018-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
AZY0075823336C0003X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2176895OtherPK
AZ380554Medicaid