Basic Information
| Provider Information | |||||||||
| NPI: | 1629392667 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SMITHS FOOD & DRUG CENTERS INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | FRYS FOOD AND DRUG | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | P.O. BOX 842772 | ||||||||
| Address2: | |||||||||
| City: | BOSTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 02284 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5137621019 | ||||||||
| FaxNumber: | 5137621092 | ||||||||
| Practice Location | |||||||||
| Address1: | 16380 W YUMA RD | ||||||||
| Address2: | |||||||||
| City: | GOODYEAR | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 853383100 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6239254442 | ||||||||
| FaxNumber: | 6239254443 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/19/2010 | ||||||||
| LastUpdateDate: | 07/19/2018 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MUENNICH | ||||||||
| AuthorizedOfficialFirstName: | ALLISON | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | MANAGER OF PHARMACY LICENSING | ||||||||
| AuthorizedOfficialTelephone: | 5137621019 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 333600000X | N | Suppliers | Pharmacy | 332B00000X | N | Suppliers | Durable Medical Equipment & Medical Supplies | 3336C0003X | Y005254 | AZ | Y | Suppliers | Pharmacy | Community/Retail Pharmacy |
ID Information
| ID | Type | State | Issuer | Description | 2124150 | 01 | PK | OTHER | 510549 | 05 | AZ | MEDICAID |