Provider Demographics
NPI:1730295684
Name:STATE OF ARIZONA
Entity Type:Organization
Organization Name:STATE OF ARIZONA
Other - Org Name:U OF COLLEGE OF PHCY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIR MEDICATION MNGMNT CNTR
Authorized Official - Prefix:
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:BOESEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:520-626-3981
Mailing Address - Street 1:PO BOX 210602
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85721-0001
Mailing Address - Country:US
Mailing Address - Phone:520-626-3981
Mailing Address - Fax:520-626-6026
Practice Address - Street 1:1295 N MARTIN
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85721-0001
Practice Address - Country:US
Practice Address - Phone:520-626-3981
Practice Address - Fax:520-626-6026
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-22
Last Update Date:2012-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ17003336C0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0002XSuppliersPharmacyClinic Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
0314067OtherNCPDP PROVIDER IDENTIFICATION NUMBER