Provider Demographics
NPI:1033135074
Name:STATE OF NEW MEXICO
Entity Type:Organization
Organization Name:STATE OF NEW MEXICO
Other - Org Name:NEW MEXICO STATE VETERANS PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATIVE SERVICES DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MARIE
Authorized Official - Middle Name:R
Authorized Official - Last Name:RICHTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:575-894-4216
Mailing Address - Street 1:992 S BROADWAY
Mailing Address - Street 2:
Mailing Address - City:TRUTH OR CONSEQUENCES
Mailing Address - State:NM
Mailing Address - Zip Code:87901
Mailing Address - Country:US
Mailing Address - Phone:575-894-4200
Mailing Address - Fax:575-894-4291
Practice Address - Street 1:992 S BROADWAY
Practice Address - Street 2:
Practice Address - City:TRUTH OR CONSEQUENCES
Practice Address - State:NM
Practice Address - Zip Code:87901
Practice Address - Country:US
Practice Address - Phone:575-894-4200
Practice Address - Fax:575-894-4291
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-14
Last Update Date:2017-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMCS00021264183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM65755Medicaid
NM3208774OtherMEDICARE D