1750411096 NPI number — WILFRED CHAVEZ PHRAMACIST

Table of content: WILFRED CHAVEZ PHRAMACIST (NPI 1750411096)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1750411096 NPI number — WILFRED CHAVEZ PHRAMACIST

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CHAVEZ
Provider First Name:
WILFRED
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PHRAMACIST
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:
1750411096
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
701 DALIES AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BELEN
Provider Business Mailing Address State Name:
NM
Provider Business Mailing Address Postal Code:
87002-3617
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
505-864-7471
Provider Business Mailing Address Fax Number:
505-864-6535

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
701 DALIES AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BELEN
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
87002-3617
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
505-864-7471
Provider Business Practice Location Address Fax Number:
505-864-6535
Provider Enumeration Date:
03/06/2007

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: 3336C0004X , with the licence number:  CS00208115 , 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: CS00208115 . This is a "LICENSE NUMBER" identifier , issued by the state of ( NM ) . This identifiers is of the category "OTHER".




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