Provider Demographics
NPI:1093024275
Name:CIBOLA GENERAL HOSPITAL PHCY
Entity Type:Organization
Organization Name:CIBOLA GENERAL HOSPITAL PHCY
Other - Org Name:CIBOLA GENERAL HOSPITAL PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF PHARMACY
Authorized Official - Prefix:
Authorized Official - First Name:ANDREW
Authorized Official - Middle Name:
Authorized Official - Last Name:HALL
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:505-287-5320
Mailing Address - Street 1:1016 E ROOSEVELT AVE
Mailing Address - Street 2:
Mailing Address - City:GRANTS
Mailing Address - State:NM
Mailing Address - Zip Code:87020-2118
Mailing Address - Country:US
Mailing Address - Phone:505-287-5320
Mailing Address - Fax:505-287-5325
Practice Address - Street 1:1016 E ROOSEVELT AVE
Practice Address - Street 2:
Practice Address - City:GRANTS
Practice Address - State:NM
Practice Address - Zip Code:87020-2118
Practice Address - Country:US
Practice Address - Phone:505-287-5320
Practice Address - Fax:505-287-5325
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-10-05
Last Update Date:2010-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMPH000021503336I0012X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336I0012XSuppliersPharmacyInstitutional Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
3204625OtherNCPDP PROVIDER IDENTIFICATION NUMBER
NM00729Medicaid