Provider Demographics
NPI:1538264791
Name:GERIATRIC SERVICES OF AMERICA, INC.
Entity type:Organization
Organization Name:GERIATRIC SERVICES OF AMERICA, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:
Authorized Official - Last Name:RHEAULT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:480-967-9203
Mailing Address - Street 1:PO BOX 13034
Mailing Address - Street 2:
Mailing Address - City:TEMPE
Mailing Address - State:AZ
Mailing Address - Zip Code:85284-0051
Mailing Address - Country:US
Mailing Address - Phone:480-967-9203
Mailing Address - Fax:480-838-6920
Practice Address - Street 1:5030 S MILL AVE
Practice Address - Street 2:SUITE D-23
Practice Address - City:TEMPE
Practice Address - State:AZ
Practice Address - Zip Code:85282-6833
Practice Address - Country:US
Practice Address - Phone:480-967-9203
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-13
Last Update Date:2008-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ24553336S0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE100251178-00Medicaid
KY90009796Medicaid
OK200020690BMedicaid
NE100251178-00Medicaid
NE100251178-00Medicaid