Healthcare Provider Details

I. General information

NPI: 1801592555
Provider Name (Legal Business Name): COMMUNITY CLINICAL PHARMACY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/03/2023
Last Update Date: 02/03/2023
Certification Date: 02/03/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2045 S VINEYARD STE 133
MESA AZ
85210-6893
US

IV. Provider business mailing address

2045 S VINEYARD STE 133
MESA AZ
85210-6893
US

V. Phone/Fax

Practice location:
  • Phone: 480-969-0600
  • Fax: 480-969-0712
Mailing address:
  • Phone: 480-969-0600
  • Fax: 480-969-0712

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State

VII. Legacy identifiers

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

VIII. Authorized Official

Name: DR. RYAN COHEN
Title or Position: PHARMACIST-IN-CHARGE
Credential: PHARMD
Phone: 480-969-0600