Provider Demographics
NPI:1821009499
Name:MG PHARMACY
Entity Type:Organization
Organization Name:MG PHARMACY
Other - Org Name:MG PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MORRIS
Authorized Official - Middle Name:
Authorized Official - Last Name:GORTLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:602-439-3366
Mailing Address - Street 1:4025 W BELL RD
Mailing Address - Street 2:STE 1A
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85053-2750
Mailing Address - Country:US
Mailing Address - Phone:602-439-3366
Mailing Address - Fax:
Practice Address - Street 1:4025 W BELL RD
Practice Address - Street 2:STE 1A
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85053-2750
Practice Address - Country:US
Practice Address - Phone:602-439-3366
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-10
Last Update Date:2012-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
AZ0017683336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
0314396OtherNCPDP PROVIDER IDENTIFICATION NUMBER
AZ078958Medicaid