Provider Demographics
NPI:1841219128
Name:ADDISON DRUG
Entity Type:Organization
Organization Name:ADDISON DRUG
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:M
Authorized Official - Last Name:ADDISON
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:505-355-2211
Mailing Address - Street 1:PO BOX 550
Mailing Address - Street 2:127 E. SUMNER AVENUE
Mailing Address - City:FORT SUMNER
Mailing Address - State:NM
Mailing Address - Zip Code:88119-0550
Mailing Address - Country:US
Mailing Address - Phone:505-355-2211
Mailing Address - Fax:505-355-7816
Practice Address - Street 1:323 SUMNER AVE
Practice Address - Street 2:
Practice Address - City:FORT SUMNER
Practice Address - State:NM
Practice Address - Zip Code:88119-0550
Practice Address - Country:US
Practice Address - Phone:505-355-2211
Practice Address - Fax:505-355-7816
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-18
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMPH00001147183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM56390Medicaid
NM3202253OtherNCPDP NUMBER