Basic Information
| Provider Information | |||||||||
| NPI: | 1851607444 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | 1ST CARE PHARMACY LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | 1ST CARE PHARMACY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1300 S WATSON RD STE 104A | ||||||||
| Address2: | |||||||||
| City: | BUCKEYE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 853266264 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6232513201 | ||||||||
| FaxNumber: | 6232513205 | ||||||||
| Practice Location | |||||||||
| Address1: | 1300 S WATSON RD STE 104A | ||||||||
| Address2: | |||||||||
| City: | BUCKEYE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 853266264 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6232513201 | ||||||||
| FaxNumber: | 6232513205 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/20/2010 | ||||||||
| LastUpdateDate: | 10/25/2010 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | NYAKWEBA | ||||||||
| AuthorizedOfficialFirstName: | LAMECK | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PHARMACY DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 6239329800 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 333600000X | N | Suppliers | Pharmacy | 3336C0004X | N | Suppliers | Pharmacy | Compounding Pharmacy | 3336C0003X | Y005289 | AZ | Y | Suppliers | Pharmacy | Community/Retail Pharmacy |
ID Information
| ID | Type | State | Issuer | Description | 0356801 | 01 | NCPDP PROVIDER IDENTIFICATION NUMBER | OTHER |