Provider Demographics
NPI:1619179983
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:480-895-5370
Mailing Address - Fax:480-895-5371
Practice Address - Street 1:99 S HIGLEY RD
Practice Address - Street 2:
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85296-1168
Practice Address - Country:US
Practice Address - Phone:480-926-5221
Practice Address - Fax:480-926-5223
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-31
Last Update Date:2022-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0003X
AZY0047573336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ0354744OtherNCPDP
AZ211736Medicaid
AZFB0238279OtherDEA LICENSE
AZ211736Medicaid
AZ0354744OtherNCPDP