Provider Demographics
NPI:1841586773
Name:PHOENIX CHILDREN'S HOSPITAL
Entity Type:Organization
Organization Name:PHOENIX CHILDREN'S HOSPITAL
Other - Org Name:PHOENIX CHILDREN'S OUTPATIENT PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT & C.E.O.
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:MEYER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:602-933-0400
Mailing Address - Street 1:1919 E THOMAS RD
Mailing Address - Street 2:ATTN: RETAIL PHARMACY
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85016-7710
Mailing Address - Country:US
Mailing Address - Phone:602-933-2048
Mailing Address - Fax:602-933-2057
Practice Address - Street 1:1919 E THOMAS RD
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85016-7710
Practice Address - Country:US
Practice Address - Phone:602-933-2048
Practice Address - Fax:602-933-2057
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-06-20
Last Update Date:2018-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0004X
AZY0016443336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ621764Medicaid
2130676OtherPK
AZ612764Medicaid