Provider Demographics
NPI:1598966798
Name:STATE OF NEW MEXICO
Entity Type:Organization
Organization Name:STATE OF NEW MEXICO
Other - Org Name:NEW MEXICO BEHAVIORAL HEALTH INSTITUE AT LAS VEGAS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACY DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:DAN
Authorized Official - Middle Name:
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:505-454-2183
Mailing Address - Street 1:3695 HOT SPRINGS BLVD
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NM
Mailing Address - Zip Code:87701-9549
Mailing Address - Country:US
Mailing Address - Phone:505-454-2183
Mailing Address - Fax:505-454-2182
Practice Address - Street 1:3695 HOT SPRINGS BLVD
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NM
Practice Address - Zip Code:87701-9549
Practice Address - Country:US
Practice Address - Phone:505-454-2183
Practice Address - Fax:505-454-2182
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-29
Last Update Date:2016-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336L0003X
NMPH000021053336I0012X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336I0012XSuppliersPharmacyInstitutional Pharmacy
No333600000XSuppliersPharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM61788Medicaid
2056964OtherPK