Basic Information
| Provider Information | |||||||||
| NPI: | 1578741120 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MOUNTAIN PARK HEALTH CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3003 N CENTRAL AVE STE 1600 | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850122908 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6023233242 | ||||||||
| FaxNumber: | 6023233496 | ||||||||
| Practice Location | |||||||||
| Address1: | 6601 W THOMAS RD | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850335700 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6023238181 | ||||||||
| FaxNumber: | 6022471238 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/06/2008 | ||||||||
| LastUpdateDate: | 11/21/2019 | ||||||||
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| AuthorizedOfficialLastName: | SOTO | ||||||||
| AuthorizedOfficialFirstName: | MARY | ||||||||
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| AuthorizedOfficialTitleorPosition: | ASSOCIATE PHARMACY DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 6025863026 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | MOUNTAIN PARK HEALTH CENTER | ||||||||
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| AuthorizedOfficialCredential: | PHARMD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3336C0002X | 4078 | AZ | Y | Suppliers | Pharmacy | Clinic Pharmacy |
ID Information
| ID | Type | State | Issuer | Description | 914912 | 05 | AZ | MEDICAID | 4078 | 01 | AZ | BOARD OF PHARMACY | OTHER |