Healthcare Provider Details

I. General information

NPI: 1255796496
Provider Name (Legal Business Name): MAYO CLINIC ARIZONA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/15/2015
Last Update Date: 08/11/2025
Certification Date: 08/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5881 E MAYO BLVD # STE 1-304
PHOENIX AZ
85054-4505
US

IV. Provider business mailing address

PO BOX 083268
CHICAGO IL
60691-0268
US

V. Phone/Fax

Practice location:
  • Phone: 480-342-4100
  • Fax: 480-342-4180
Mailing address:
  • Phone: 507-284-3390
  • Fax:

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 NumberY006569
License Number StateAZ
# 3
Primary TaxonomyN
Taxonomy Code3336I0012X
TaxonomyInstitutional Pharmacy
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: ROSHANAK DIDEHBAN
Title or Position: CAO
Credential:
Phone: 480-301-6493