1306861166 NPI number — CHARLES NMI VANDIVER R.PH., PH.C.

Table of content: CHARLES NMI VANDIVER R.PH., PH.C. (NPI 1306861166)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1306861166 NPI number — CHARLES NMI VANDIVER R.PH., PH.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
VANDIVER
Provider First Name:
CHARLES
Provider Middle Name:
NMI
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
R.PH., PH.C.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1306861166
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/07/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 307
Provider Second Line Business Mailing Address:
11 PRESTON TRAIL
Provider Business Mailing Address City Name:
ANGEL FIRE
Provider Business Mailing Address State Name:
NM
Provider Business Mailing Address Postal Code:
87710-0307
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
505-377-2548
Provider Business Mailing Address Fax Number:
505-377-2548

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1422 PASEO DE PERALTA
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SANTA FE
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
87501-4391
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
505-289-3291
Provider Business Practice Location Address Fax Number:
505-289-3648
Provider Enumeration Date:
07/13/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1835P1200X , with the licence number:  PC00000033 , registered in the state of NM ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 4458 . This is a "REGISTERED PHARMACIST #" identifier , issued by the state of ( NM ) . This identifiers is of the category "OTHER".
  • Identifier: PC00000033 . This is a "PHARMACIST CLINICIAN NUM" identifier , issued by the state of ( NM ) . This identifiers is of the category "OTHER".
  • Identifier: CS00021140 . This is a "NM CONTROLLED SUBST. NUM" identifier , issued by the state of ( NM ) . This identifiers is of the category "OTHER".




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