Provider Demographics
NPI:1154461341
Name:REDE PHARMACY, INC
Entity Type:Organization
Organization Name:REDE PHARMACY, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER-PHARMACIST
Authorized Official - Prefix:MR
Authorized Official - First Name:MAHMOOD
Authorized Official - Middle Name:
Authorized Official - Last Name:HURAB
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:505-522-7484
Mailing Address - Street 1:2655 MISSOURI
Mailing Address - Street 2:
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88011-5023
Mailing Address - Country:US
Mailing Address - Phone:505-522-7484
Mailing Address - Fax:505-522-5652
Practice Address - Street 1:2655 MISSOURI
Practice Address - Street 2:
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88011-5023
Practice Address - Country:US
Practice Address - Phone:505-522-7484
Practice Address - Fax:505-522-5652
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-07
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMPH000017463336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM61096Medicaid