Provider Demographics
NPI:1659478493
Name:SCOTTSDALE PROFESSIONAL PHARMACY LTD
Entity Type:Organization
Organization Name:SCOTTSDALE PROFESSIONAL PHARMACY LTD
Other - Org Name:SCOTTSDALE PROFESSIONAL PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:SARAH
Authorized Official - Middle Name:KATHRYN
Authorized Official - Last Name:SIMMERS
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:480-946-9477
Mailing Address - Street 1:10900 N SCOTTSDALE RD STE 403
Mailing Address - Street 2:10900 N SCOTTSDALE RD STE 403
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85254-5218
Mailing Address - Country:US
Mailing Address - Phone:480-946-9477
Mailing Address - Fax:480-946-1345
Practice Address - Street 1:10900 N SCOTTSDALE RD
Practice Address - Street 2:SUITE 403
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85254-5216
Practice Address - Country:US
Practice Address - Phone:480-946-9477
Practice Address - Fax:480-946-1345
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-20
Last Update Date:2022-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0003X
AZY0012313336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
1997302OtherPK
AZ031584Medicaid