Provider Demographics
NPI:1255591418
Name:HAVASU HEALTH CARE PHARM
Entity type:Organization
Organization Name:HAVASU HEALTH CARE PHARM
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:
Authorized Official - Last Name:DAHLBERG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:928-855-9888
Mailing Address - Street 1:3560 CHALLENGER DR
Mailing Address - Street 2:STE 106
Mailing Address - City:LAKE HAVASU CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:86406-9152
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3560 CHALLENGER DR
Practice Address - Street 2:STE 106
Practice Address - City:LAKE HAVASU CITY
Practice Address - State:AZ
Practice Address - Zip Code:86406-9152
Practice Address - Country:US
Practice Address - Phone:928-855-9888
Practice Address - Fax:928-855-9888
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-11
Last Update Date:2008-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3336M0003X
AZY00049843336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No3336M0003XSuppliersPharmacyManaged Care Organization Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
0355366OtherOTHER ID NUMBER