Basic Information
| Provider Information | |||||||||
| NPI: | 1255796496 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MAYO CLINIC ARIZONA | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | MAYO CLINIC BUILDING PHOENIX OUTPATIENT PHARMACY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
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| OtherCredential: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 21 2ND ST SW | ||||||||
| Address2: | SUITE 1-18 | ||||||||
| City: | ROCHESTER | ||||||||
| State: | MN | ||||||||
| PostalCode: | 559023026 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5072843390 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 5881 E MAYO BLVD. | ||||||||
| Address2: | #1-304 | ||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850544505 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4803424100 | ||||||||
| FaxNumber: | 4803424180 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/15/2015 | ||||||||
| LastUpdateDate: | 04/12/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | VIRAMONTES | ||||||||
| AuthorizedOfficialFirstName: | ALLISON | ||||||||
| 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 | N | Suppliers | Pharmacy | 3336C0003X | N | Suppliers | Pharmacy | Community/Retail Pharmacy | 3336I0012X | N | Suppliers | Pharmacy | Institutional Pharmacy | 3336C0002X | Y006569 | AZ | Y | Suppliers | Pharmacy | Clinic Pharmacy |
ID Information
| ID | Type | State | Issuer | Description | 2155895 | 01 | PK | OTHER |