Provider Demographics
NPI:1912918582
Name:UPTOWN PHARMACY OF KINGMAN , INC
Entity Type:Organization
Organization Name:UPTOWN PHARMACY OF KINGMAN , INC
Other - Org Name:UPTOWN DRUG NORTH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CHRIS
Authorized Official - Middle Name:HOWARD
Authorized Official - Last Name:PROFFIT
Authorized Official - Suffix:
Authorized Official - Credentials:B S PHARMACY
Authorized Official - Phone:928-757-1131
Mailing Address - Street 1:4495 N BANK ST
Mailing Address - Street 2:STE 1
Mailing Address - City:KINGMAN
Mailing Address - State:AZ
Mailing Address - Zip Code:86409-2711
Mailing Address - Country:US
Mailing Address - Phone:928-757-1131
Mailing Address - Fax:928-757-1108
Practice Address - Street 1:4495 N BANK ST
Practice Address - Street 2:STE 1
Practice Address - City:KINGMAN
Practice Address - State:AZ
Practice Address - Zip Code:86409-2711
Practice Address - Country:US
Practice Address - Phone:928-757-1131
Practice Address - Fax:928-757-1108
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-10
Last Update Date:2017-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZY007032333600000X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ235645Medicaid
1988479OtherPK