Healthcare Provider Details

I. General information

NPI: 1306033881
Provider Name (Legal Business Name): COMMUNITY DRUGSTORE II LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/28/2007
Last Update Date: 04/23/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

777 W SOUTHERN AVE 415
MESA AZ
85210-5008
US

IV. Provider business mailing address

7701 E GRAY RD SUITE 107
SCOTTSDALE AZ
85260-6958
US

V. Phone/Fax

Practice location:
  • Phone: 480-464-5472
  • Fax: 480-464-5485
Mailing address:
  • Phone: 602-468-6337
  • Fax: 480-212-4933

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License NumberY004893
License Number StateAZ

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier263561
Identifier TypeMEDICAID
Identifier StateAZ
Identifier Issuer
# 2
Identifier0355025
Identifier TypeOTHER
Identifier State
Identifier IssuerNCPDP PROVIDER IDENTIFICATION NUMBER

VIII. Authorized Official

Name: JOANNA GUBERNICK
Title or Position: MANAGER
Credential:
Phone: 602-468-6337