Provider Demographics
NPI:1386732279
Name:RALEY'S ARIZONA LLC
Entity type:Organization
Organization Name:RALEY'S ARIZONA LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF PHARMACY
Authorized Official - Prefix:
Authorized Official - First Name:MIKE
Authorized Official - Middle Name:
Authorized Official - Last Name:MCKINLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:480-895-5372
Mailing Address - Street 1:PO BOX 488
Mailing Address - Street 2:
Mailing Address - City:CHANDLER
Mailing Address - State:AZ
Mailing Address - Zip Code:85244-0488
Mailing Address - Country:US
Mailing Address - Phone:480-895-5349
Mailing Address - Fax:480-895-5214
Practice Address - Street 1:5555 N 7TH ST
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85014-2584
Practice Address - Country:US
Practice Address - Phone:602-277-6133
Practice Address - Fax:602-277-6136
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-10
Last Update Date:2022-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0003X
AZY0040123336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
0328383OtherNCPDP PROVIDER IDENTIFICATION NUMBER
AZ854548Medicaid
0328383OtherNCPDP PROVIDER IDENTIFICATION NUMBER