Provider Demographics
NPI:1295887552
Name:MIXTURES PHARMACY LLC
Entity type:Organization
Organization Name:MIXTURES PHARMACY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LORI
Authorized Official - Middle Name:
Authorized Official - Last Name:ALLEN
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:480-706-0620
Mailing Address - Street 1:16515 S 40TH ST STE 123
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85048-0559
Mailing Address - Country:US
Mailing Address - Phone:480-706-0620
Mailing Address - Fax:480-706-0489
Practice Address - Street 1:16515 S 40TH ST STE 123
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85048-0559
Practice Address - Country:US
Practice Address - Phone:480-706-0620
Practice Address - Fax:480-706-0489
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-17
Last Update Date:2022-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZYO3896183500000X
AZ39863336C0004X
AZ38963336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty
No3336C0004XSuppliersPharmacyCompounding PharmacyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ1295887552Medicaid