Basic Information
| Provider Information | |||||||||
| NPI: | 1598864134 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | AMERITA, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6912 S QUENTIN ST STE 50 | ||||||||
| Address2: | |||||||||
| City: | CENTENNIAL | ||||||||
| State: | CO | ||||||||
| PostalCode: | 801124531 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7202825411 | ||||||||
| FaxNumber: | 8773025251 | ||||||||
| Practice Location | |||||||||
| Address1: | 3775 CROSSINGS DR | ||||||||
| Address2: | |||||||||
| City: | PRESCOTT | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 863057138 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9287080025 | ||||||||
| FaxNumber: | 9287080916 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/21/2006 | ||||||||
| LastUpdateDate: | 09/15/2021 | ||||||||
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| AuthorizedOfficialLastName: | IRIYE | ||||||||
| AuthorizedOfficialFirstName: | RICHARD | ||||||||
| AuthorizedOfficialMiddleName: | D | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7202822377 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | AMERITA, INC. | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| NPICertificationDate: | 09/15/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251F00000X | N | Agencies | Home Infusion | 332B00000X | Y005977 | AZ | N | Suppliers | Durable Medical Equipment & Medical Supplies | 332BP3500X | Y005977 | AZ | N | Suppliers | Durable Medical Equipment & Medical Supplies | Parenteral & Enteral Nutrition | 3336S0011X | N | Suppliers | Pharmacy | Specialty Pharmacy | 3336H0001X | Y005977 | AZ | Y | Suppliers | Pharmacy | Home Infusion Therapy Pharmacy |
ID Information
| ID | Type | State | Issuer | Description | 320692 | 01 | AZ | NCPDP | OTHER | FA4665379 | 01 | DEA | OTHER | Y007460 | 01 | AZ | PHARMACY | OTHER |