NPIMap

Organization Active NPI

Northern Arizona Pharmacy LLC

Doing business as Chino Valley Pharmacy

  • Pharmacy
  • Chino Valley, AZ
National Provider Identifier
1194175588
Registry record updated Dec 20, 2019
On this page

Key facts

NPPES NPI Registry
Primary specialty
PharmacyTaxonomy code 333600000X
License
Y006900 Issued in AZ
Legal business name
NORTHERN ARIZONA PHARMACY LLC
Doing business as
Chino Valley Pharmacy
Practice address
1932 N State Route 89
Chino Valley, AZ 86323-5643
Phone
(928) 515-0046
Fax
(928) 515-0047
NPI assigned
Jun 15, 2016
Last updated
Dec 20, 2019By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Dec 20, 2019

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Dr. Jason James Dykstra, PHARMDNPI 1801126024
Title
Pharmacist
Phone
(928) 515-0046

Authorized official NPPES reports the official by name only. The link goes to the one practitioner with that name whose NPPES practice address or phone number is this organization’s.

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Pharmacy 333600000X Y006900 AZ Primary
Community/Retail Pharmacy 3336C0003X NU

Addresses

Primary practice location

1932 N State Route 89
Chino Valley, AZ 86323-5643

Mailing address

1932 N State Route 89
Chino Valley, AZ 86323-5643
Phone (928) 515-0046

Other identifiers 2

IdentifierTypeStateIssuer
171606MedicaidAZ
2160678OtherPK

Other names 1

  • Chino Valley Pharmacy Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in AZ

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20170727002043 AZ Part B Supplier - Mass Immunization (Roster Biller Only) 9234409939 2 other NPIs on this enrollment
Practice locations: Chino Valley, AZ; Dewey, AZ; Mayer, AZ

Other NPIs on the same Medicare enrollment 2

NPIs listed together on one Medicare enrollment, typically parts of the same organization.

Laboratory certificates & supplier records

Derived by NPIMap

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

CLIA numberLaboratoryCertificateExpires
03D2209291Northern Arizona Pharmacy1932 N State Route 89, Chino Valley, AZ 86323Certificate of waiverJan 11, 2027

National Provider Directory

National Provider Directory
Tax ID family
Dewey Pharmacy4 organizations share this tax ID, including this one

Other organizations with this tax ID 3

Organizations that report the same tax identification number in the National Provider Directory.

Locations

1932 N State Route 89
Chino Valley, AZ 86323
Phone (928) 515-0046

Practitioners & affiliated clinicians

Practitioners 1

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1465948800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1576800000000",
    "number": "1194175588",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1932 N STATE ROUTE 89",
            "city": "CHINO VALLEY",
            "state": "AZ",
            "postal_code": "863235643",
            "telephone_number": "928-515-0046",
            "fax_number": "928-515-0047"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1932 N STATE ROUTE 89",
            "city": "CHINO VALLEY",
            "state": "AZ",
            "postal_code": "863235643",
            "telephone_number": "928-515-0046",
            "fax_number": "928-515-0047"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "NORTHERN ARIZONA PHARMACY LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2016-06-15",
        "last_updated": "2019-12-20",
        "certification_date": "2019-12-20",
        "status": "A",
        "authorized_official_last_name": "DYKSTRA",
        "authorized_official_first_name": "JASON",
        "authorized_official_middle_name": "JAMES",
        "authorized_official_title_or_position": "PHARMACIST",
        "authorized_official_telephone_number": "928-515-0046",
        "authorized_official_name_prefix": "Dr.",
        "authorized_official_credential": "PHARMD"
    },
    "taxonomies": [
        {
            "code": "333600000X",
            "taxonomy_group": "",
            "desc": "Pharmacy",
            "state": "AZ",
            "license": "Y006900",
            "primary": true
        },
        {
            "code": "3336C0003X",
            "taxonomy_group": "",
            "desc": "Pharmacy, Community/Retail Pharmacy",
            "state": "NU",
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "171606",
            "state": "AZ"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "PK",
            "identifier": "2160678",
            "state": null
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Chino Valley Pharmacy",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Chino Valley Pharmacy",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Chino Valley, AZ

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Dec 20, 2019; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.