Provider Demographics
NPI:1760099980
Name:PORTILLO, ANGELICA ENEZ (RPH)
Entity Type:Individual
Prefix:
First Name:ANGELICA
Middle Name:ENEZ
Last Name:PORTILLO
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 1:10600 COORS BYPASS NW
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87114-3930
Mailing Address - Country:US
Mailing Address - Phone:505-922-0847
Mailing Address - Fax:505-922-0966
Practice Address - Street 1:10600 COORS BYP NW
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87114-3930
Practice Address - Country:US
Practice Address - Phone:505-922-0847
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-01
Last Update Date:2023-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM9327183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist