Provider Demographics
NPI:1336456235
Name:CORDOVA, MARK RICHARD (RPH)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:RICHARD
Last Name:CORDOVA
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 1:608 GRECIAN AVE NW
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87107-5729
Mailing Address - Country:US
Mailing Address - Phone:505-344-6368
Mailing Address - Fax:
Practice Address - Street 1:6001 LOMAS BLVD NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87110-6618
Practice Address - Country:US
Practice Address - Phone:505-266-7433
Practice Address - Fax:505-265-7384
Is Sole Proprietor?:No
Enumeration Date:2010-09-13
Last Update Date:2010-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMRP00004939183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist