Basic Information
| Provider Information | |||||||||
| NPI: | 1003000746 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GALLEGOS | ||||||||
| FirstName: | MIKE | ||||||||
| MiddleName: | LEE | ||||||||
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| Credential: | PHC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 221 STATE HIGHWAY 165 | ||||||||
| Address2: | A-4 | ||||||||
| City: | PLACITAS | ||||||||
| State: | NM | ||||||||
| PostalCode: | 87043 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5058670733 | ||||||||
| FaxNumber: | 5057850886 | ||||||||
| Practice Location | |||||||||
| Address1: | 221 STATE HIGHWAY 165 | ||||||||
| Address2: | A-4 | ||||||||
| City: | PLACITAS | ||||||||
| State: | NM | ||||||||
| PostalCode: | 87043 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5058670733 | ||||||||
| FaxNumber: | 5057850886 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/05/2007 | ||||||||
| LastUpdateDate: | 08/02/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/02/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 183500000X | 6838 | NM | Y | Pharmacy Service Providers | Pharmacist |
No ID Information.