Provider Demographics
NPI:1407907496
Name:QUINTANAS FAIRVIEW PHARMACY INC
Entity Type:Organization
Organization Name:QUINTANAS FAIRVIEW PHARMACY INC
Other - Org Name:FAIRVIEW PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:LARRY
Authorized Official - Middle Name:
Authorized Official - Last Name:QUINTANA
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:505-753-2209
Mailing Address - Street 1:734 N RIVERSIDE DR
Mailing Address - Street 2:STE A
Mailing Address - City:ESPANOLA
Mailing Address - State:NM
Mailing Address - Zip Code:87532-2957
Mailing Address - Country:US
Mailing Address - Phone:505-753-2209
Mailing Address - Fax:505-753-8408
Practice Address - Street 1:734 N RIVERSIDE DR
Practice Address - Street 2:STE A
Practice Address - City:ESPANOLA
Practice Address - State:NM
Practice Address - Zip Code:87532-2957
Practice Address - Country:US
Practice Address - Phone:505-753-2209
Practice Address - Fax:505-753-8408
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-16
Last Update Date:2014-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
NMPH000011413336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2057691OtherPK
NM55731Medicaid