Provider Demographics
NPI:1780786186
Name:WESTERN DRUG INC
Entity type:Organization
Organization Name:WESTERN DRUG INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:FRED
Authorized Official - Middle Name:
Authorized Official - Last Name:HARPER
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:928-333-2916
Mailing Address - Street 1:PO BOX 517
Mailing Address - Street 2:
Mailing Address - City:SAINT JOHNS
Mailing Address - State:AZ
Mailing Address - Zip Code:85936-0517
Mailing Address - Country:US
Mailing Address - Phone:928-337-2229
Mailing Address - Fax:928-337-2500
Practice Address - Street 1:1155 W CLEVELAND
Practice Address - Street 2:
Practice Address - City:ST JOHNS
Practice Address - State:AZ
Practice Address - Zip Code:85936
Practice Address - Country:US
Practice Address - Phone:928-337-2229
Practice Address - Fax:928-337-2500
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-05
Last Update Date:2016-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
AZY0034773336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
1997484OtherPK
AZ618887Medicaid