Provider Demographics
NPI:1629390554
Name:TSO, ELLIOTT MELVIN (PHARMD)
Entity Type:Individual
Prefix:
First Name:ELLIOTT
Middle Name:MELVIN
Last Name:TSO
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4600 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:NM
Mailing Address - Zip Code:87402-8603
Mailing Address - Country:US
Mailing Address - Phone:505-326-1197
Mailing Address - Fax:
Practice Address - Street 1:4600 E MAIN ST
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:NM
Practice Address - Zip Code:87402-8603
Practice Address - Country:US
Practice Address - Phone:505-326-1197
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-02-19
Last Update Date:2015-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMRP00007327183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist