Provider Demographics
NPI:1619685443
Name:THAYER, MADELYN
Entity Type:Individual
Prefix:
First Name:MADELYN
Middle Name:
Last Name:THAYER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4979 E KARSTEN DR
Mailing Address - Street 2:
Mailing Address - City:CHANDLER
Mailing Address - State:AZ
Mailing Address - Zip Code:85249-7175
Mailing Address - Country:US
Mailing Address - Phone:480-433-9669
Mailing Address - Fax:
Practice Address - Street 1:18495 E QUEEN CREEK RD
Practice Address - Street 2:
Practice Address - City:QUEEN CREEK
Practice Address - State:AZ
Practice Address - Zip Code:85142-3597
Practice Address - Country:US
Practice Address - Phone:480-279-0521
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-10
Last Update Date:2023-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3336C0003X
AZS026199183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy