Healthcare Provider Details

I. General information

NPI: 1093960031
Provider Name (Legal Business Name): COMMUNITY DRUGSTORE III LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/18/2008
Last Update Date: 03/02/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2222 E HIGHLAND AVE
PHOENIX AZ
85016-4872
US

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 602-682-7660
  • Fax: 602-682-7753
Mailing address:
  • Phone: 602-468-6337
  • Fax: 480-212-4933

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3336C0002X
TaxonomyClinic Pharmacy
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License NumberY005063
License Number StateAZ
# 4
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: JOANNA GUBERNICK
Title or Position: ADMINISTRATOR
Credential:
Phone: 480-281-1406