Provider Demographics
NPI:1538512363
Name:JAFFE, MICHAEL (RPH)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:JAFFE
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 1:201 PINNACLE DRIVE
Mailing Address - Street 2:APT. 3622
Mailing Address - City:RIO RANCHO
Mailing Address - State:NM
Mailing Address - Zip Code:87124-0997
Mailing Address - Country:US
Mailing Address - Phone:505-358-8798
Mailing Address - Fax:
Practice Address - Street 1:PO BOX 467
Practice Address - Street 2:
Practice Address - City:ZUNI
Practice Address - State:NM
Practice Address - Zip Code:87327-0467
Practice Address - Country:US
Practice Address - Phone:505-782-4431
Practice Address - Fax:505-782-7405
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-17
Last Update Date:2018-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPHA0021706183500000X
NMRP00008075183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
COPHA0021706OtherCOLORADO BOARD OF PHARMACY
NMRP00008075OtherNEW MEXICO BOARD OF PHARMACY