MEDICARE: COMMUNITY DRUGSTORE VI 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	3336C0003X	Community/Retail Pharmacy	Y005259	AZ

General Provider Information

NPI Number	:	1376867218
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COMMUNITY DRUGSTORE VI LLC

Provider Business Mailing Address
First Line	:	7701 E GRAY RD STE 107
Second Line	:
City	:	SCOTTSDALE
State	:	AZ
Zip	:	85260-6958
Country	:	US
Telephone Number	:	602-468-6337
Fax Number	:

Provider Business Practice Location Address
First Line	:	9305 W THOMAS RD STE 185
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85037-3361
Country	:	US
Telephone Number	:	602-468-6337
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	STEPHEN GUBERNICK
Credential	:
Telephone Number	:	602-468-6337

Provider Enumeration Date	:	03/22/2010
Last Update Date	:	03/22/2010

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