Provider Demographics
NPI:1659939171
Name:ONTHEGO PHARMACY
Entity Type:Organization
Organization Name:ONTHEGO PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACY MANAGER/DELEGATED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:ALLEN
Authorized Official - Last Name:ROE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:602-607-5094
Mailing Address - Street 1:15830 N 35TH AVE STE 3
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85053-7640
Mailing Address - Country:US
Mailing Address - Phone:026-075-0946
Mailing Address - Fax:
Practice Address - Street 1:15830 N 35TH AVE
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85053-7640
Practice Address - Country:US
Practice Address - Phone:602-607-5094
Practice Address - Fax:602-926-2370
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-05-30
Last Update Date:2020-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ589383Medicaid