Provider Demographics
NPI:1942918644
Name:MEDINA, ANGELICA (RPH)
Entity Type:Individual
Prefix:
First Name:ANGELICA
Middle Name:
Last Name:MEDINA
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1035 N 150TH DR
Mailing Address - Street 2:
Mailing Address - City:GOODYEAR
Mailing Address - State:AZ
Mailing Address - Zip Code:85338-5694
Mailing Address - Country:US
Mailing Address - Phone:630-303-7399
Mailing Address - Fax:
Practice Address - Street 1:25401 N LAKE PLEASANT PKWY
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:AZ
Practice Address - Zip Code:85383-1351
Practice Address - Country:US
Practice Address - Phone:623-235-2360
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-10
Last Update Date:2022-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZS026206183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist