Provider Demographics
NPI:1306033881
Name:COMMUNITY DRUGSTORE II LLC
Entity Type:Organization
Organization Name:COMMUNITY DRUGSTORE II LLC
Other - Org Name:COMMUNITY PHARMACY II
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JOANNA
Authorized Official - Middle Name:
Authorized Official - Last Name:GUBERNICK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:602-468-6337
Mailing Address - Street 1:7701 E GRAY RD
Mailing Address - Street 2:SUITE 107
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85260-6958
Mailing Address - Country:US
Mailing Address - Phone:602-468-6337
Mailing Address - Fax:480-212-4933
Practice Address - Street 1:777 W SOUTHERN AVE
Practice Address - Street 2:415
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85210-5008
Practice Address - Country:US
Practice Address - Phone:480-464-5472
Practice Address - Fax:480-464-5485
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-28
Last Update Date:2010-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0004X
AZY0048933336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ263561Medicaid
0355025OtherNCPDP PROVIDER IDENTIFICATION NUMBER