Provider Demographics
NPI:1831594704
Name:ETUKEREN, ETUKEREN
Entity type:Individual
Prefix:
First Name:ETUKEREN
Middle Name:
Last Name:ETUKEREN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13014 W CAMELBACK RD
Mailing Address - Street 2:
Mailing Address - City:LITCHFIELD PARK
Mailing Address - State:AZ
Mailing Address - Zip Code:85340-9401
Mailing Address - Country:US
Mailing Address - Phone:623-935-0528
Mailing Address - Fax:623-935-0549
Practice Address - Street 1:13014 W CAMELBACK RD
Practice Address - Street 2:
Practice Address - City:LITCHFIELD PARK
Practice Address - State:AZ
Practice Address - Zip Code:85340-9401
Practice Address - Country:US
Practice Address - Phone:623-935-0528
Practice Address - Fax:623-935-0549
Is Sole Proprietor?:Yes
Enumeration Date:2014-11-04
Last Update Date:2014-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZS021016183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist