Provider Demographics
NPI:1669483236
Name:MARYVALE PHARMACY INC
Entity Type:Organization
Organization Name:MARYVALE PHARMACY INC
Other - Org Name:M D PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:
Authorized Official - Last Name:BATES
Authorized Official - Suffix:
Authorized Official - Credentials:BS CHE BSPHARM
Authorized Official - Phone:623-846-1888
Mailing Address - Street 1:4700 N 51ST AVE STE 1
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85031-1237
Mailing Address - Country:US
Mailing Address - Phone:623-846-1888
Mailing Address - Fax:623-848-8202
Practice Address - Street 1:4700 N 51ST AVE STE 1
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85031-1237
Practice Address - Country:US
Practice Address - Phone:623-846-1888
Practice Address - Fax:623-848-8202
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-10
Last Update Date:2016-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X, 3336C0004X
AZY0028813336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
1997277OtherPK
AZ380379Medicaid
AZ380379Medicaid