Basic Information
| Provider Information | |||||||||
| NPI: | 1477650075 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MARANA HEALTH CENTER | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | MARANA PHARMACY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 13644 N SANDARIO RD | ||||||||
| Address2: | |||||||||
| City: | MARANA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 856538579 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5206821095 | ||||||||
| FaxNumber: | 5206822196 | ||||||||
| Practice Location | |||||||||
| Address1: | 13644 N SANDARIO RD | ||||||||
| Address2: | |||||||||
| City: | MARANA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 856538579 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5206821095 | ||||||||
| FaxNumber: | 5206822196 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/19/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | REDDING | ||||||||
| AuthorizedOfficialFirstName: | GREGORY | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | PHARMACY DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 5206821095 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | PHARM D | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 302R00000X | 4075 | AZ | Y | Managed Care Organizations | Health Maintenance Organization |
No ID Information.