Healthcare Provider Details

I. General information

NPI: 1902877855
Provider Name (Legal Business Name): MAYO CLINIC ARIZONA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/30/2006
Last Update Date: 08/11/2025
Certification Date: 08/11/2025
Deactivation Date: 01/06/2012
Reactivation Date: 10/10/2012

III. Provider practice location address

5777 E MAYO BLVD
PHOENIX AZ
85054-4502
US

IV. Provider business mailing address

13400 E SHEA BLVD
SCOTTSDALE AZ
85259-5404
US

V. Phone/Fax

Practice location:
  • Phone: 480-301-0881
  • Fax:
Mailing address:
  • Phone: 480-301-8000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number4044
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code3336C0002X
TaxonomyClinic Pharmacy
License Number4044
License Number StateAZ
# 3
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