Provider Demographics
NPI:1477564029
Name:LA FARMACIA
Entity Type:Organization
Organization Name:LA FARMACIA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER MGR
Authorized Official - Prefix:
Authorized Official - First Name:LEO
Authorized Official - Middle Name:
Authorized Official - Last Name:WINK
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:505-753-2327
Mailing Address - Street 1:PO 3708 FAIRVIEW STATION
Mailing Address - Street 2:
Mailing Address - City:ESPANOLA
Mailing Address - State:NM
Mailing Address - Zip Code:87532
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:544 N PASEO DE ONATE
Practice Address - Street 2:
Practice Address - City:ESPANOLA
Practice Address - State:NM
Practice Address - Zip Code:87532-2618
Practice Address - Country:US
Practice Address - Phone:505-753-2327
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-10
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMPH00001142333600000X
3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered333600000XSuppliersPharmacy
Not Answered3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
3205817OtherOTHER ID NUMBER-COMMERCIAL NUMBER
NM054064Medicaid