Provider Demographics
NPI:1265629596
Name:BLACK, M. SUE PULLIN (RPH)
Entity Type:Individual
Prefix:MRS
First Name:M. SUE
Middle Name:PULLIN
Last Name:BLACK
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4500 ALEXANDER BLVD NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87107-6805
Mailing Address - Country:US
Mailing Address - Phone:505-345-8080
Mailing Address - Fax:
Practice Address - Street 1:4500 ALEXANDER BLVD NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87107-6805
Practice Address - Country:US
Practice Address - Phone:505-345-8080
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-10-01
Last Update Date:2007-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMRP00007001183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMRP00007001OtherNM BD. OF PHARMACY