Provider Demographics
NPI:1831314707
Name:CROWNPOINT HEALTH CARE FACILITY
Entity Type:Organization
Organization Name:CROWNPOINT HEALTH CARE FACILITY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:STACY
Authorized Official - Middle Name:
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:505-786-6344
Mailing Address - Street 1:PO BOX 358
Mailing Address - Street 2:
Mailing Address - City:CROWNPOINT
Mailing Address - State:NM
Mailing Address - Zip Code:87313-0358
Mailing Address - Country:US
Mailing Address - Phone:505-786-6344
Mailing Address - Fax:505-786-6440
Practice Address - Street 1:HWY 371 ROUTE 9
Practice Address - Street 2:
Practice Address - City:CROWNPOINT
Practice Address - State:NM
Practice Address - Zip Code:87313-0358
Practice Address - Country:US
Practice Address - Phone:505-786-6344
Practice Address - Fax:505-786-6440
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-16
Last Update Date:2008-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMAU47208463336C0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0002XSuppliersPharmacyClinic Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ021189Medicaid
NM47209Medicaid
NM47209Medicaid