Provider Demographics
NPI:1922196823
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 1:8035 E INDIAN SCHOOL RD
Mailing Address - Street 2:
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85251-2617
Mailing Address - Country:US
Mailing Address - Phone:480-663-1043
Mailing Address - Fax:480-663-1044
Practice Address - Street 1:8035 E INDIAN SCHOOL RD
Practice Address - Street 2:
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85251-2617
Practice Address - Country:US
Practice Address - Phone:480-663-1043
Practice Address - Fax:480-663-1044
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-10
Last Update Date:2022-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0003X
AZY0040163336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
0352194OtherNCPDP PROVIDER IDENTIFICATION NUMBER
AZ880163Medicaid