Provider Demographics
NPI:1013312925
Name:EAST VALLEY DERMATOLOGY RX, LLC
Entity Type:Organization
Organization Name:EAST VALLEY DERMATOLOGY RX, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:480-821-8888
Mailing Address - Street 1:1100 S DOBSON RD
Mailing Address - Street 2:#223
Mailing Address - City:CHANDLER
Mailing Address - State:AZ
Mailing Address - Zip Code:85286-6157
Mailing Address - Country:US
Mailing Address - Phone:480-821-8888
Mailing Address - Fax:480-821-0888
Practice Address - Street 1:1100 S DOBSON RD
Practice Address - Street 2:#223
Practice Address - City:CHANDLER
Practice Address - State:AZ
Practice Address - Zip Code:85286-6157
Practice Address - Country:US
Practice Address - Phone:480-821-8888
Practice Address - Fax:480-821-0888
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-11-04
Last Update Date:2019-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ26816207N00000X
332900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes332900000XSuppliersNon-Pharmacy Dispensing SiteGroup - Single Specialty
No207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty