Provider Demographics
NPI:1336335058
Name:BIG PARK PHARMACY LLC
Entity Type:Organization
Organization Name:BIG PARK PHARMACY LLC
Other - Org Name:SEDONA COMPOUNDING PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:GREGG
Authorized Official - Middle Name:
Authorized Official - Last Name:HUSER
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:602-740-0451
Mailing Address - Street 1:3150 W STATE ROUTE 89A STE 5
Mailing Address - Street 2:
Mailing Address - City:SEDONA
Mailing Address - State:AZ
Mailing Address - Zip Code:86336-4924
Mailing Address - Country:US
Mailing Address - Phone:928-284-9593
Mailing Address - Fax:928-284-9605
Practice Address - Street 1:3150 W STATE ROUTE 89A STE 5
Practice Address - Street 2:
Practice Address - City:SEDONA
Practice Address - State:AZ
Practice Address - Zip Code:86336-4924
Practice Address - Country:US
Practice Address - Phone:928-284-9593
Practice Address - Fax:928-284-9605
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-17
Last Update Date:2011-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3336C0003X
AZY029893336C0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0004XSuppliersPharmacyCompounding Pharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
0323129OtherNCPDP PROVIDER IDENTIFICATION NUMBER