Provider Demographics
NPI:1730287749
Name:UNITED DRUG & LIQUOR INC
Entity Type:Organization
Organization Name:UNITED DRUG & LIQUOR INC
Other - Org Name:UNITED DRUG
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:GREG
Authorized Official - Middle Name:
Authorized Official - Last Name:MITCHELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:575-267-4943
Mailing Address - Street 1:PO BOX 427
Mailing Address - Street 2:
Mailing Address - City:HATCH
Mailing Address - State:NM
Mailing Address - Zip Code:87937-0427
Mailing Address - Country:US
Mailing Address - Phone:575-267-4943
Mailing Address - Fax:575-267-3327
Practice Address - Street 1:221 W HALL ST
Practice Address - Street 2:
Practice Address - City:HATCH
Practice Address - State:NM
Practice Address - Zip Code:87937-0427
Practice Address - Country:US
Practice Address - Phone:575-267-4943
Practice Address - Fax:575-267-3327
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-21
Last Update Date:2016-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
NMPH000013733336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM63040Medicaid
2057075OtherPK
2057075OtherPK