Provider Demographics
NPI:1558415992
Name:PORTABLE MEDICAL PHARMACY
Entity Type:Organization
Organization Name:PORTABLE MEDICAL PHARMACY
Other - Org Name:SPECTRUM PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:
Authorized Official - Last Name:TOOMEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:702-491-6447
Mailing Address - Street 1:5538 DUNCAN DR
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89130-2812
Mailing Address - Country:US
Mailing Address - Phone:702-939-6562
Mailing Address - Fax:702-939-6569
Practice Address - Street 1:6250 E GRANT RD
Practice Address - Street 2:STE 388
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85712-5805
Practice Address - Country:US
Practice Address - Phone:520-296-0317
Practice Address - Fax:520-296-0417
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-23
Last Update Date:2017-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0004X
AZ42923336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
1991946OtherPK
AZ962755Medicaid