Provider Demographics
NPI:1891800819
Name:RALEY'S ARIZONA LLC
Entity Type:Organization
Organization Name:RALEY'S ARIZONA LLC
Other - Org Name:BASHAS
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 1:20351 N LAKE PLEASANT RD
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:AZ
Mailing Address - Zip Code:85382-9703
Mailing Address - Country:US
Mailing Address - Phone:623-537-2321
Mailing Address - Fax:623-537-2323
Practice Address - Street 1:20351 N LAKE PLEASANT RD
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:AZ
Practice Address - Zip Code:85382-9703
Practice Address - Country:US
Practice Address - Phone:623-537-2321
Practice Address - Fax:623-537-2323
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-20
Last Update Date:2022-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0003X
AZY0036773336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
0327622OtherNCPDP PROVIDER IDENTIFICATION NUMBER
AZ774449Medicaid
0327622OtherNCPDP PROVIDER IDENTIFICATION NUMBER