Provider Demographics
NPI:1003000746
Name:GALLEGOS, MIKE LEE (PHC)
Entity Type:Individual
Prefix:
First Name:MIKE
Middle Name:LEE
Last Name:GALLEGOS
Suffix:
Gender:M
Credentials:PHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:221 STATE HIGHWAY 165
Mailing Address - Street 2:A-4
Mailing Address - City:PLACITAS
Mailing Address - State:NM
Mailing Address - Zip Code:87043
Mailing Address - Country:US
Mailing Address - Phone:505-867-0733
Mailing Address - Fax:505-785-0886
Practice Address - Street 1:221 STATE HIGHWAY 165
Practice Address - Street 2:A-4
Practice Address - City:PLACITAS
Practice Address - State:NM
Practice Address - Zip Code:87043
Practice Address - Country:US
Practice Address - Phone:505-867-0733
Practice Address - Fax:505-785-0886
Is Sole Proprietor?:No
Enumeration Date:2007-09-05
Last Update Date:2021-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM6838183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist