Provider Demographics
NPI:1982152732
Name:FREEDOM PHARMACY OF ARIZONA AT RED MOUNTAIN LLC
Entity Type:Organization
Organization Name:FREEDOM PHARMACY OF ARIZONA AT RED MOUNTAIN LLC
Other - Org Name:FREEDOM PHARMACY OF ARIZONA AT RED MOUNTAIN
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CHRIS
Authorized Official - Middle Name:
Authorized Official - Last Name:SHALER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:480-993-9646
Mailing Address - Street 1:8035 E BROWN RD
Mailing Address - Street 2:BLDG 4, STE C
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85207
Mailing Address - Country:US
Mailing Address - Phone:480-565-7222
Mailing Address - Fax:480-499-0396
Practice Address - Street 1:8035 E BROWN RD
Practice Address - Street 2:BLDG 4, STE C
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85207-3901
Practice Address - Country:US
Practice Address - Phone:480-565-7222
Practice Address - Fax:480-499-0396
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-09-21
Last Update Date:2018-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
AZY0069203336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2164187OtherPK
AZ238769Medicaid