Provider Demographics
NPI:1306861166
Name:VANDIVER, CHARLES NMI (RPH, PHC)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:NMI
Last Name:VANDIVER
Suffix:
Gender:M
Credentials:RPH, 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 307
Mailing Address - Street 2:11 PRESTON TRAIL
Mailing Address - City:ANGEL FIRE
Mailing Address - State:NM
Mailing Address - Zip Code:87710-0307
Mailing Address - Country:US
Mailing Address - Phone:505-377-2548
Mailing Address - Fax:505-377-2548
Practice Address - Street 1:1422 PASEO DE PERALTA
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87501-4391
Practice Address - Country:US
Practice Address - Phone:505-289-3291
Practice Address - Fax:505-289-3648
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-13
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMPC000000331835P1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P1200XPharmacy Service ProvidersPharmacistPharmacotherapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM4458OtherREGISTERED PHARMACIST #
NMPC00000033OtherPHARMACIST CLINICIAN NUM
NMCS00021140OtherNM CONTROLLED SUBST. NUM
NMCS00021140OtherNM CONTROLLED SUBST. NUM