Provider Demographics
NPI:1093496382
Name:TARANGO-MORENO, EDSON
Entity Type:Individual
Prefix:
First Name:EDSON
Middle Name:
Last Name:TARANGO-MORENO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5201 CENTRAL AVE NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87108-1328
Mailing Address - Country:US
Mailing Address - Phone:505-217-9907
Mailing Address - Fax:
Practice Address - Street 1:5201 CENTRAL AVE NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87108-1328
Practice Address - Country:US
Practice Address - Phone:505-217-9907
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-28
Last Update Date:2023-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMRP00009969183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist