Provider Demographics
NPI:1447255187
Name:APOTHECARY SHOP OF MESA INC
Entity type:Organization
Organization Name:APOTHECARY SHOP OF MESA INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:MUSIL
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:623-434-3650
Mailing Address - Street 1:23620 N 20TH DR
Mailing Address - Street 2:STE 12
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85085-0621
Mailing Address - Country:US
Mailing Address - Phone:623-434-3650
Mailing Address - Fax:623-434-3676
Practice Address - Street 1:1432 S DOBSON RD
Practice Address - Street 2:STE 101
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85202-4769
Practice Address - Country:US
Practice Address - Phone:480-969-9595
Practice Address - Fax:480-969-9494
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-17
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ4155333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ915267Medicaid
AZ915267Medicaid