Provider Demographics
NPI:1083729008
Name:RALEY'S ARIZONA LLC
Entity Type:Organization
Organization Name:RALEY'S ARIZONA LLC
Other - Org Name:BASHAS UNITED DRUG
Other - Org Type:Doing Business As
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:DEPT 3
Mailing Address - City:CHANDLER
Mailing Address - State:AZ
Mailing Address - Zip Code:85244-0488
Mailing Address - Country:US
Mailing Address - Phone:480-895-9350
Mailing Address - Fax:480-895-5371
Practice Address - Street 1:3269 MARICOPA AVE
Practice Address - Street 2:STE 120
Practice Address - City:LAKE HAVASU CITY
Practice Address - State:AZ
Practice Address - Zip Code:86406-8593
Practice Address - Country:US
Practice Address - Phone:928-854-9551
Practice Address - Fax:928-854-9553
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-20
Last Update Date:2022-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0003X
AZY0036783336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
0327432OtherNCPDP PROVIDER IDENTIFICATION NUMBER
AZ739063Medicaid
AZ739063Medicaid