Provider Demographics
NPI:1538216684
Name:JAREKO LLC
Entity type:Organization
Organization Name:JAREKO LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:OLUFEMI
Authorized Official - Middle Name:
Authorized Official - Last Name:OMODARA
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:602-277-5444
Mailing Address - Street 1:4207 N 19TH AVE
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85015-5116
Mailing Address - Country:US
Mailing Address - Phone:602-277-5444
Mailing Address - Fax:602-274-8821
Practice Address - Street 1:4207 N 19TH AVE
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85015-5116
Practice Address - Country:US
Practice Address - Phone:602-277-5444
Practice Address - Fax:602-274-8821
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-04
Last Update Date:2012-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
AZY0043183336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
0353285OtherNCPDP PROVIDER IDENTIFICATION NUMBER
AZ977316Medicaid
5618680001Medicare NSC