Provider Demographics
NPI:1659382208
Name:PARKHURST PHARMACY
Entity Type:Organization
Organization Name:PARKHURST PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:PHIL
Authorized Official - Middle Name:
Authorized Official - Last Name:PARKHURST
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:505-287-4641
Mailing Address - Street 1:1208 BONITA ST
Mailing Address - Street 2:
Mailing Address - City:GRANTS
Mailing Address - State:NM
Mailing Address - Zip Code:87020-2234
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1208 BONITA ST
Practice Address - Street 2:
Practice Address - City:GRANTS
Practice Address - State:NM
Practice Address - Zip Code:87020-2234
Practice Address - Country:US
Practice Address - Phone:505-287-4641
Practice Address - Fax:505-287-7160
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
NMPH00001150333600000X
3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered333600000XSuppliersPharmacy
Not Answered3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
3202366OtherOTHER ID NUMBER-COMMERCIAL NUMBER
NM55103Medicaid
0552440001Medicare ID - Type Unspecified