Provider Demographics
NPI:1548408230
Name:COMMUNITY DRUG STORE, LLC
Entity Type:Organization
Organization Name:COMMUNITY DRUG STORE, LLC
Other - Org Name:COMMUNITY PHARMACY IV
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:
Authorized Official - Last Name:GUBERNICK
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:480-575-1103
Mailing Address - Street 1:7305 E VISAO DR
Mailing Address - Street 2:
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85266-2707
Mailing Address - Country:US
Mailing Address - Phone:480-575-1103
Mailing Address - Fax:602-298-6934
Practice Address - Street 1:3050 N WINDSONG DR
Practice Address - Street 2:SUITE 103
Practice Address - City:PRESCOTT VALLEY
Practice Address - State:AZ
Practice Address - Zip Code:86314-2265
Practice Address - Country:US
Practice Address - Phone:480-575-1103
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-02-03
Last Update Date:2009-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZY0051063336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy