Basic Information
| Provider Information | |||||||||
| NPI: | 1891246773 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | JOHN C LINCOLN, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | DEER VALLEY PHARMACY | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2500 W UTOPIA RD | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850274171 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6234346200 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 19636 N 27TH AVE | ||||||||
| Address2: | SUITE 308 | ||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850274013 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6237801999 | ||||||||
| FaxNumber: | 6235160950 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/17/2016 | ||||||||
| LastUpdateDate: | 03/31/2017 | ||||||||
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| AuthorizedOfficialLastName: | ANSPACH | ||||||||
| AuthorizedOfficialFirstName: | NATHAN | ||||||||
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| AuthorizedOfficialTitleorPosition: | SR. VICE PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 6234346200 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332900000X | AZ | Y | Suppliers | Non-Pharmacy Dispensing Site |
No ID Information.