1649311374 NPI number — MICHAEL'S PRESCRIPTION CORNER

Table of content: (NPI 1649311374)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1649311374 NPI number — MICHAEL'S PRESCRIPTION CORNER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MICHAEL'S PRESCRIPTION CORNER
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
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:
1649311374
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/18/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
123 W AVENUE A
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LOVINGTON
Provider Business Mailing Address State Name:
NM
Provider Business Mailing Address Postal Code:
88260-4211
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
575-396-2311
Provider Business Mailing Address Fax Number:
575-396-2321

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
123 W AVENUE A
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LOVINGTON
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
88260-4211
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
575-396-2311
Provider Business Practice Location Address Fax Number:
575-396-2321
Provider Enumeration Date:
02/08/2007

Additional Information

Authorized Official

Authorized Official Last Name:
RABURN
Authorized Official First Name:
MICHAEL
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
505-396-2311

Provider Taxonomy Codes

  • Taxonomy code: 3336C0003X , with the licence number:  CS00208480 , registered in the state of NM ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 3336C0004X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 3202873 . This is a "NCPDP PROVIDER IDENTIFICATION NUMBER" identifier . This identifiers is of the category "OTHER".
  • Identifier: 55061 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".




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