Provider Demographics
NPI:1639100803
Name:APOTHECARY SHOP OF SANDY INC
Entity Type:Organization
Organization Name:APOTHECARY SHOP OF SANDY INC
Other - Org Name:SOUTHWOOD APOTHECARY SHOP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VP OF OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:NATHAN
Authorized Official - Middle Name:
Authorized Official - Last Name:DOWNHOUR
Authorized Official - Suffix:
Authorized Official - Credentials:PHRMD
Authorized Official - Phone:623-434-3654
Mailing Address - Street 1:1606 W WHISPERING WIND DR
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85085-0678
Mailing Address - Country:US
Mailing Address - Phone:623-434-3659
Mailing Address - Fax:623-434-3673
Practice Address - Street 1:880 E 9400 S
Practice Address - Street 2:STE 118
Practice Address - City:SANDY
Practice Address - State:UT
Practice Address - Zip Code:84094-3667
Practice Address - Country:US
Practice Address - Phone:801-571-0340
Practice Address - Fax:801-576-8938
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:APOTHECARY HOLDINGS INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-07-06
Last Update Date:2009-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT697078117033336C0003X
3336C0004X, 3336S0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
4603165OtherNCPDP PROVIDER IDENTIFICATION NUMBER
67629OtherMEDICARE - MASS IMMUNIZATION ROSTER BILLER
UT8703064560008Medicaid
6176650001Medicare NSC