Provider Demographics
NPI:1043629678
Name:CORDOVA, CRESTINA (PHARMD)
Entity Type:Individual
Prefix:
First Name:CRESTINA
Middle Name:
Last Name:CORDOVA
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:224 PASEO DEL PUEBLO SUR
Mailing Address - Street 2:
Mailing Address - City:TAOS
Mailing Address - State:NM
Mailing Address - Zip Code:87571-6413
Mailing Address - Country:US
Mailing Address - Phone:575-758-4823
Mailing Address - Fax:
Practice Address - Street 1:224 PASEO DEL PUEBLO SUR
Practice Address - Street 2:
Practice Address - City:TAOS
Practice Address - State:NM
Practice Address - Zip Code:87571-6413
Practice Address - Country:US
Practice Address - Phone:575-758-4823
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-07
Last Update Date:2014-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMRP00008191183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist