Provider Demographics
NPI:1952533556
Name:SUN VALLEY PHARMACY LLC
Entity Type:Organization
Organization Name:SUN VALLEY PHARMACY LLC
Other - Org Name:SUN VALLEY PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:HALIM
Authorized Official - Middle Name:
Authorized Official - Last Name:HASSANI
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:928-927-5300
Mailing Address - Street 1:PO BOX 4620
Mailing Address - Street 2:
Mailing Address - City:QUARTZSITE
Mailing Address - State:AZ
Mailing Address - Zip Code:85359-4620
Mailing Address - Country:US
Mailing Address - Phone:480-294-3391
Mailing Address - Fax:928-927-5299
Practice Address - Street 1:219 W PIMA
Practice Address - Street 2:
Practice Address - City:GILA BEND
Practice Address - State:AZ
Practice Address - Zip Code:85353
Practice Address - Country:US
Practice Address - Phone:928-927-5300
Practice Address - Fax:928-927-5299
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-08-14
Last Update Date:2010-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZY0051693336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
0356293OtherNCPDP PROVIDER IDENTIFICATION NUMBER
AZ470280Medicaid