Provider Demographics
NPI:1821416751
Name:MICHAEL'S PRESCRIPTION CORNER
Entity Type:Organization
Organization Name:MICHAEL'S PRESCRIPTION CORNER
Other - Org Name:NORTE VISTA
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:RABURN
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:575-392-2311
Mailing Address - Street 1:2420 N FOWLER ST
Mailing Address - Street 2:
Mailing Address - City:HOBBS
Mailing Address - State:NM
Mailing Address - Zip Code:88240-2347
Mailing Address - Country:US
Mailing Address - Phone:575-392-2311
Mailing Address - Fax:575-392-2321
Practice Address - Street 1:2420 N FOWLER ST
Practice Address - Street 2:
Practice Address - City:HOBBS
Practice Address - State:NM
Practice Address - Zip Code:88240-2347
Practice Address - Country:US
Practice Address - Phone:575-392-2311
Practice Address - Fax:575-392-2321
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-03-28
Last Update Date:2022-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMPH000036593336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM14439310Medicaid