Provider Demographics
NPI:1043436595
Name:LARRAGOITE, MARK (RPH)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:
Last Name:LARRAGOITE
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:MR
Other - First Name:G
Other - Middle Name:MARK
Other - Last Name:LARRAGOITE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:RPH
Mailing Address - Street 1:9409 OAKMONT RD NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87111-5822
Mailing Address - Country:US
Mailing Address - Phone:505-857-9252
Mailing Address - Fax:
Practice Address - Street 1:2801 EUBANK BLVD NE STE A
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87112-1300
Practice Address - Country:US
Practice Address - Phone:505-294-1597
Practice Address - Fax:505-275-0340
Is Sole Proprietor?:No
Enumeration Date:2007-04-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMRP00004609183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMRP00004609OtherRPH LICENSE-PROVIDER ID