Provider Demographics
NPI:1134617889
Name:STONERIDGE PHARMACY LLC
Entity type:Organization
Organization Name:STONERIDGE PHARMACY LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ZACH
Authorized Official - Middle Name:
Authorized Official - Last Name:HANKS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-419-9388
Mailing Address - Street 1:3737 E HANS DR
Mailing Address - Street 2:
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85296-1421
Mailing Address - Country:US
Mailing Address - Phone:801-419-9388
Mailing Address - Fax:480-393-7663
Practice Address - Street 1:2235 S 1300 W
Practice Address - Street 2:
Practice Address - City:WEST VALLEY CITY
Practice Address - State:UT
Practice Address - Zip Code:84119-7241
Practice Address - Country:US
Practice Address - Phone:801-419-9388
Practice Address - Fax:480-393-7663
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-04-27
Last Update Date:2018-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2177412OtherPK