Basic Information
| Provider Information | |||||||||
| NPI: | 1386276160 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CORRALES PHARMACY INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 221 STATE HIGHWAY 165 # A4 | ||||||||
| Address2: | A4 | ||||||||
| City: | PLACITAS | ||||||||
| State: | NM | ||||||||
| PostalCode: | 870439514 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5054806327 | ||||||||
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| Practice Location | |||||||||
| Address1: | 221 STATE HIGHWAY 165 # A4 | ||||||||
| Address2: | A4 | ||||||||
| City: | PLACITAS | ||||||||
| State: | NM | ||||||||
| PostalCode: | 870439514 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5054806327 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/10/2020 | ||||||||
| LastUpdateDate: | 02/10/2020 | ||||||||
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| AuthorizedOfficialLastName: | GALLEGOS | ||||||||
| AuthorizedOfficialFirstName: | MIKE | ||||||||
| AuthorizedOfficialMiddleName: | LEE | ||||||||
| AuthorizedOfficialTitleorPosition: | PIC OWNER | ||||||||
| AuthorizedOfficialTelephone: | 5054806327 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | CORRALES PHARMACY | ||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | PHARMD, PC | ||||||||
| NPICertificationDate: | 02/10/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3336C0002X | Y | Suppliers | Pharmacy | Clinic Pharmacy |
No ID Information.