Provider Demographics
NPI:1578921094
Name:MESA NEIGHBORHOOD PHARMACY LLC
Entity Type:Organization
Organization Name:MESA NEIGHBORHOOD PHARMACY LLC
Other - Org Name:PHOENIX PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:VITTELIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:FORBES
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:602-237-6677
Mailing Address - Street 1:1701 E THOMAS RD
Mailing Address - Street 2:SUITE 105
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85016-7646
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1701 E THOMAS RD
Practice Address - Street 2:SUITE 105
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85016-7646
Practice Address - Country:US
Practice Address - Phone:480-329-9585
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-01-29
Last Update Date:2023-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZY0067303336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy