Provider Demographics
NPI:1932830205
Name:NORTHERN ARIZONA PHARMACY
Entity Type:Organization
Organization Name:NORTHERN ARIZONA PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JASON
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:DYKSTRA
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:928-515-0046
Mailing Address - Street 1:1932 N STATE ROUTE 89
Mailing Address - Street 2:
Mailing Address - City:CHINO VALLEY
Mailing Address - State:AZ
Mailing Address - Zip Code:86323-5643
Mailing Address - Country:US
Mailing Address - Phone:928-515-0046
Mailing Address - Fax:928-515-0047
Practice Address - Street 1:12075 E STATE ROUTE 69 STE E
Practice Address - Street 2:
Practice Address - City:DEWEY
Practice Address - State:AZ
Practice Address - Zip Code:86327-4569
Practice Address - Country:US
Practice Address - Phone:928-515-0455
Practice Address - Fax:928-515-0456
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-06-18
Last Update Date:2022-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ003672Medicaid