Basic Information
Provider Information | |||||||||
NPI: | 1902877855 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | MAYO CLINIC ARIZONA | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | MAYO CLINIC HOSPITAL (PHARMACY) | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 13400 E SHEA BLVD | ||||||||
Address2: |   | ||||||||
City: | SCOTTSDALE | ||||||||
State: | AZ | ||||||||
PostalCode: | 852595404 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4803018000 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 5777 E MAYO BLVD | ||||||||
Address2: |   | ||||||||
City: | PHOENIX | ||||||||
State: | AZ | ||||||||
PostalCode: | 850544502 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4803010881 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/30/2006 | ||||||||
LastUpdateDate: | 04/12/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: | 01/06/2012 | ||||||||
NPIReactivationDate: | 10/10/2012 | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | VIRAMONTES | ||||||||
AuthorizedOfficialFirstName: | ALLISOON | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CFO | ||||||||
AuthorizedOfficialTelephone: | 4803019748 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 04/12/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 333600000X | 4044 | AZ | N |   | Suppliers | Pharmacy |   | 3336C0002X | 4044 | AZ | Y |   | Suppliers | Pharmacy | Clinic Pharmacy |
No ID Information.