Provider Demographics
NPI:1447605175
Name:EDAMS LTC PHARMACY LLC
Entity type:Organization
Organization Name:EDAMS LTC PHARMACY LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:YAYA
Authorized Official - Middle Name:SIMEON
Authorized Official - Last Name:EDAMIVOH
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:602-900-3037
Mailing Address - Street 1:1735 N 11TH AVE
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85705-6527
Mailing Address - Country:US
Mailing Address - Phone:520-230-8188
Mailing Address - Fax:520-448-4841
Practice Address - Street 1:1735 N 11TH AVE
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85705-6527
Practice Address - Country:US
Practice Address - Phone:520-230-8188
Practice Address - Fax:520-448-4841
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-05-02
Last Update Date:2024-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3336L0003X
AZY0067463336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZY009864OtherLONG TERM CARE PHARMACY
2159778OtherPK