=====================================================
General NPI Number Information
=====================================================
NPI Number | 1730042292
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CANYON RIVER, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/03/2025
-----------------------------------------------------
Last Update Date | 12/03/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1328 W UNIVERSITY DR STE 103
-----------------------------------------------------
City | TEMPE
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85281-3390
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-402-8018
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1328 W UNIVERSITY DR STE 103
-----------------------------------------------------
City | TEMPE
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85281-3390
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MEMBER
-----------------------------------------------------
Name | AKSHAR PATEL
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 678-977-9009
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 3336S0011X
-----------------------------------------------------
Taxonomy Name | Specialty Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 333600000X
-----------------------------------------------------
Taxonomy Name | Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------