Provider Demographics
NPI:1447315494
Name:SAGE MEMORIAL HOSPITAL
Entity type:Organization
Organization Name:SAGE MEMORIAL HOSPITAL
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIR OF PHCY
Authorized Official - Prefix:
Authorized Official - First Name:FARID
Authorized Official - Middle Name:
Authorized Official - Last Name:KIYARASH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:928-755-4500
Mailing Address - Street 1:PO BOX 457
Mailing Address - Street 2:
Mailing Address - City:GANADO
Mailing Address - State:AZ
Mailing Address - Zip Code:86505-0457
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:HWY 264 AND 191
Practice Address - Street 2:
Practice Address - City:GANADO
Practice Address - State:AZ
Practice Address - Zip Code:86505
Practice Address - Country:US
Practice Address - Phone:928-755-4500
Practice Address - Fax:928-755-4659
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-27
Last Update Date:2009-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZY0007583336C0002X
3336M0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0002XSuppliersPharmacyClinic Pharmacy
No3336M0003XSuppliersPharmacyManaged Care Organization Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
0308949OtherNCPDP PROVIDER IDENTIFICATION NUMBER
AZ021353Medicaid