Provider Demographics
NPI:1578752762
Name:STATE OF ARIZONA
Entity Type:Organization
Organization Name:STATE OF ARIZONA
Other - Org Name:BLACK CANYON SCHOOL PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:602-520-1663
Mailing Address - Street 1:24601 N 29TH AVE
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85083-1165
Mailing Address - Country:US
Mailing Address - Phone:623-780-1303
Mailing Address - Fax:623-879-7026
Practice Address - Street 1:24601 N 29TH AVE
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85083-1165
Practice Address - Country:US
Practice Address - Phone:623-780-1303
Practice Address - Fax:623-879-7026
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-24
Last Update Date:2016-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZY019363336I0012X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336I0012XSuppliersPharmacyInstitutional Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
1988966OtherPK