Provider Demographics
NPI:1154487635
Name:PARKHURST, PHIL (RPH)
Entity Type:Individual
Prefix:
First Name:PHIL
Middle Name:
Last Name:PARKHURST
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1208 BONITA ST
Mailing Address - Street 2:
Mailing Address - City:GRANTS
Mailing Address - State:NM
Mailing Address - Zip Code:87020-2234
Mailing Address - Country:US
Mailing Address - Phone:505-287-4641
Mailing Address - Fax:505-287-7160
Practice Address - Street 1:1208 BONITA ST
Practice Address - Street 2:
Practice Address - City:GRANTS
Practice Address - State:NM
Practice Address - Zip Code:87020-2234
Practice Address - Country:US
Practice Address - Phone:505-287-4641
Practice Address - Fax:505-287-7160
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-28
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM3174183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM55103Medicaid
NMT3340Medicaid
3202366OtherNCPDP
NMT3340Medicaid