Basic Information
| Provider Information | |||||||||
| NPI: | 1326645490 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | JANUS RX | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3480 EASTERN BLVD | ||||||||
| Address2: | |||||||||
| City: | MONTGOMERY | ||||||||
| State: | AL | ||||||||
| PostalCode: | 361161700 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3348194500 | ||||||||
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| Practice Location | |||||||||
| Address1: | 17300 N DYSART RD | ||||||||
| Address2: | |||||||||
| City: | SURPRISE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 853784501 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6232489199 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/02/2020 | ||||||||
| LastUpdateDate: | 04/01/2021 | ||||||||
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| AuthorizedOfficialLastName: | MIMS | ||||||||
| AuthorizedOfficialFirstName: | KRYSTAL | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 3348194500 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 04/01/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3336L0003X | Y | Suppliers | Pharmacy | Long Term Care Pharmacy |
ID Information
| ID | Type | State | Issuer | Description | 088431 | 05 | AZ | MEDICAID |