MEDICARE: RALEY'S ARIZONA LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	333600000X	Pharmacy
2	3336C0003X	Community/Retail Pharmacy	Y003678	AZ
3	3336C0003X	Community/Retail Pharmacy

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0327432	OTHER		NCPDP PROVIDER IDENTIFICATION NUMBER
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1083729008
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RALEY'S ARIZONA LLC

Provider Business Mailing Address
First Line	:	PO BOX 488
Second Line	:	DEPT 3
City	:	CHANDLER
State	:	AZ
Zip	:	85244-0488
Country	:	US
Telephone Number	:	480-895-9350
Fax Number	:	480-895-5371

Provider Business Practice Location Address
First Line	:	3269 MARICOPA AVE
Second Line	:	STE 120
City	:	LAKE HAVASU CITY
State	:	AZ
Zip	:	86406-8593
Country	:	US
Telephone Number	:	928-854-9551
Fax Number	:	928-854-9553

Authorized Official
Title or Position	:	DIRECTOR OF PHARMACY
Name	:	MIKE MCKINLEY
Credential	:
Telephone Number	:	480-895-5372

Provider Enumeration Date	:	08/20/2006
Last Update Date	:	04/29/2022

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Directions to “RALEY'S ARIZONA LLC ” Practice Location

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