Provider Demographics
NPI:1760878821
Name:WEST KINGMAN PHARMACY LLC
Entity Type:Organization
Organization Name:WEST KINGMAN PHARMACY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACY MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KASSIE
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:VILLA
Authorized Official - Suffix:
Authorized Official - Credentials:CPHT
Authorized Official - Phone:928-377-1350
Mailing Address - Street 1:1099 E SUNRISE AVE
Mailing Address - Street 2:
Mailing Address - City:KINGMAN
Mailing Address - State:AZ
Mailing Address - Zip Code:86401-6825
Mailing Address - Country:US
Mailing Address - Phone:928-718-5418
Mailing Address - Fax:928-718-5419
Practice Address - Street 1:3135 N STOCKTON HILL RD
Practice Address - Street 2:
Practice Address - City:KINGMAN
Practice Address - State:AZ
Practice Address - Zip Code:86401
Practice Address - Country:US
Practice Address - Phone:928-718-5418
Practice Address - Fax:928-718-5419
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-04-15
Last Update Date:2019-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2151367OtherPK
AZ192215Medicaid