Provider Demographics
NPI:1114033107
Name:SEDONA GROCERY, LLC
Entity Type:Organization
Organization Name:SEDONA GROCERY, LLC
Other - Org Name:CLARK'S MARKET PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACIST IN CHARGE
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:JEFFREY
Authorized Official - Last Name:FRANKLIN
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:928-284-2202
Mailing Address - Street 1:818 S. MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:BLANDING
Mailing Address - State:UT
Mailing Address - Zip Code:84511
Mailing Address - Country:US
Mailing Address - Phone:970-925-5295
Mailing Address - Fax:
Practice Address - Street 1:100 VERDE VALLEY SCHOOL RD
Practice Address - Street 2:
Practice Address - City:SEDONA
Practice Address - State:AZ
Practice Address - Zip Code:86351
Practice Address - Country:US
Practice Address - Phone:928-284-2202
Practice Address - Fax:928-284-3776
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-22
Last Update Date:2020-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ29143336C0003X
AZY0072783336C0003X
3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ420852Medicaid
AZ420852Medicaid