Provider Demographics
NPI:1144723495
Name:MARICOPA COUNTY D.B.A. MARICOPA COUNTY DEPART
Entity type:Organization
Organization Name:MARICOPA COUNTY D.B.A. MARICOPA COUNTY DEPART
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROGRAM MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DIANE
Authorized Official - Middle Name:
Authorized Official - Last Name:DEJONGE-RYAN
Authorized Official - Suffix:
Authorized Official - Credentials:MA
Authorized Official - Phone:602-372-2544
Mailing Address - Street 1:1645 E ROOSEVELT ST
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85006-3638
Mailing Address - Country:US
Mailing Address - Phone:602-372-2544
Mailing Address - Fax:602-372-0342
Practice Address - Street 1:1645 E ROOSEVELT ST
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85006-3638
Practice Address - Country:US
Practice Address - Phone:602-372-2544
Practice Address - Fax:602-372-0342
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MARICOPA COUNTY D.B.A. MARICOPA COUNTY DEPART
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-03-13
Last Update Date:2018-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZS0223961835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy SpecialistGroup - Single Specialty