Provider Demographics
NPI:1043393077
Name:TONY PESAVENTO
Entity Type:Organization
Organization Name:TONY PESAVENTO
Other - Org Name:SPRINGER DRUG
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TONY
Authorized Official - Middle Name:
Authorized Official - Last Name:PESAVENTO
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:575-483-2356
Mailing Address - Street 1:PO BOX 427
Mailing Address - Street 2:
Mailing Address - City:SPRINGER
Mailing Address - State:NM
Mailing Address - Zip Code:87747-0427
Mailing Address - Country:US
Mailing Address - Phone:575-483-2356
Mailing Address - Fax:575-483-2225
Practice Address - Street 1:825 4TH STREET
Practice Address - Street 2:
Practice Address - City:SPRINGER
Practice Address - State:NM
Practice Address - Zip Code:87747
Practice Address - Country:US
Practice Address - Phone:575-483-2356
Practice Address - Fax:575-483-2225
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-23
Last Update Date:2013-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMPH000030523336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
3203748OtherNCPDP PROVIDER IDENTIFICATION NUMBER