=====================================================
General NPI Number Information
=====================================================
NPI Number | 1164537189
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | RALEY'S ARIZONA LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/20/2006
-----------------------------------------------------
Last Update Date | 04/18/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1133 N. ELLSWORTH
-----------------------------------------------------
City | MESA
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85207
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 480-984-3431
-----------------------------------------------------
Fax | 480-984-3689
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1133 N ELLSWORTH RD
-----------------------------------------------------
City | MESA
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85207-5140
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 480-984-3431
-----------------------------------------------------
Fax | 480-984-3689
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR OF PHARMACY
-----------------------------------------------------
Name | MIKE MCKINLEY
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 480-895-5372
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 333600000X
-----------------------------------------------------
Taxonomy Name | Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 333600000X
-----------------------------------------------------
Taxonomy Name | Pharmacy
-----------------------------------------------------
License Number | Y007130
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number | Y007130
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------