Provider Demographics
NPI:1073783460
Name:SHIRLEY, ROBERT (PHC)
Entity Type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:
Last Name:SHIRLEY
Suffix:
Gender:M
Credentials:PHC
Other - Prefix:MR
Other - First Name:BOB
Other - Middle Name:
Other - Last Name:SHIRLEY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PHC
Mailing Address - Street 1:455 SAINT MICHAELS DR
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87505-7601
Mailing Address - Country:US
Mailing Address - Phone:505-820-5287
Mailing Address - Fax:505-995-4949
Practice Address - Street 1:455 SAINT MICHAELS DR
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505-7601
Practice Address - Country:US
Practice Address - Phone:505-820-5287
Practice Address - Fax:505-995-4949
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-03
Last Update Date:2008-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM44771835P1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P1200XPharmacy Service ProvidersPharmacistPharmacotherapy