Provider Demographics
NPI:1639368004
Name:CORREA, PRISCILA MELLO (RPH)
Entity Type:Individual
Prefix:MISS
First Name:PRISCILA
Middle Name:MELLO
Last Name:CORREA
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2210 MIGUEL CHAVEZ RD
Mailing Address - Street 2:# 1515
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87505-6923
Mailing Address - Country:US
Mailing Address - Phone:505-577-6391
Mailing Address - Fax:
Practice Address - Street 1:2210 MIGUEL CHAVEZ RD
Practice Address - Street 2:# 1515
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505-6923
Practice Address - Country:US
Practice Address - Phone:505-577-6391
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-22
Last Update Date:2007-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMRP00006769183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMRP00006769OtherPHARMACIST