Provider Demographics
NPI:1912918590
Name:KINGMAN HOMETOWN PHARMACY LLC
Entity Type:Organization
Organization Name:KINGMAN HOMETOWN PHARMACY LLC
Other - Org Name:KINGMAN HOMETOWN PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MGR
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:VELEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:928-681-4888
Mailing Address - Street 1:2370 NORTHERN AVE STE A
Mailing Address - Street 2:
Mailing Address - City:KINGMAN
Mailing Address - State:AZ
Mailing Address - Zip Code:86409-2573
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2370 NORTHERN AVE STE A
Practice Address - Street 2:
Practice Address - City:KINGMAN
Practice Address - State:AZ
Practice Address - Zip Code:86409-2573
Practice Address - Country:US
Practice Address - Phone:928-681-4888
Practice Address - Fax:928-681-4534
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:KINGMAN HOMETOWN PHARMACY LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-08-10
Last Update Date:2008-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ4304333600000X
3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
0352992OtherOTHER ID NUMBER-COMMERCIAL NUMBER