Provider Demographics
NPI:1225151988
Name:ADDISON, ROBERT MARION (PHC)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:MARION
Last Name:ADDISON
Suffix:
Gender:M
Credentials:PHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 550
Mailing Address - Street 2:
Mailing Address - City:FORT SUMNER
Mailing Address - State:NM
Mailing Address - Zip Code:88119-0550
Mailing Address - Country:US
Mailing Address - Phone:505-355-7357
Mailing Address - Fax:505-355-7816
Practice Address - Street 1:42121 US HWY 70
Practice Address - Street 2:
Practice Address - City:PORTALES
Practice Address - State:NM
Practice Address - Zip Code:88130-0510
Practice Address - Country:US
Practice Address - Phone:505-356-6652
Practice Address - Fax:505-359-6827
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMPC000000151835P1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P1200XPharmacy Service ProvidersPharmacistPharmacotherapy