Provider Demographics
NPI:1659703460
Name:MIXTURES PHARMACY LLC
Entity Type:Organization
Organization Name:MIXTURES PHARMACY LLC
Other - Org Name:MIXTURES PHARMACY & COMPOUNDING CENTER GILBERT
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:LORI
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:ALLEN
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:480-226-1946
Mailing Address - Street 1:16515 S 40TH STREET
Mailing Address - Street 2:SUITE 123
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85048
Mailing Address - Country:US
Mailing Address - Phone:480-706-0620
Mailing Address - Fax:480-706-0489
Practice Address - Street 1:2730 S VAL VISTA DRIVE
Practice Address - Street 2:BUILDING 1, SUITE 102
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85295
Practice Address - Country:US
Practice Address - Phone:480-300-5279
Practice Address - Fax:480-300-5649
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MIXTURES PHARMACY LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-08-02
Last Update Date:2022-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZY0056713336C0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZY005671OtherARIZONA STATE BOARD OF PHARMACY
AZ1659703460Medicaid