Provider Demographics
NPI:1083807069
Name:FARMACIA DEL PUEBLO INC
Entity Type:Organization
Organization Name:FARMACIA DEL PUEBLO INC
Other - Org Name:FARMACIA DEL PUEBLO
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:
Authorized Official - Last Name:TYLER
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:702-544-3998
Mailing Address - Street 1:2644 KINGHORN PL
Mailing Address - Street 2:
Mailing Address - City:HENDERSON
Mailing Address - State:NV
Mailing Address - Zip Code:89044-8796
Mailing Address - Country:US
Mailing Address - Phone:702-544-3998
Mailing Address - Fax:702-616-7087
Practice Address - Street 1:2123 CIVIC CENTER DR
Practice Address - Street 2:
Practice Address - City:NORTH LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89030-6327
Practice Address - Country:US
Practice Address - Phone:702-399-9477
Practice Address - Fax:702-399-7570
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-22
Last Update Date:2012-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0004X, 3336S0011X
NVPH022383336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2990629OtherNCPDP PROVIDER IDENTIFICATION NUMBER
NV100512761Medicaid