Provider Demographics
NPI:1841392073
Name:RALEY'S OF NEW MEXICO, INC.
Entity Type:Organization
Organization Name:RALEY'S OF NEW MEXICO, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACY ASSISTANT/TECHNICIAN
Authorized Official - Prefix:
Authorized Official - First Name:PATTI
Authorized Official - Middle Name:
Authorized Official - Last Name:GLUNZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:916-376-6983
Mailing Address - Street 1:500 W CAPITOL AVE
Mailing Address - Street 2:
Mailing Address - City:WEST SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95605-2624
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1100 PASEO DEL PUEBLO SUR
Practice Address - Street 2:
Practice Address - City:TOAS
Practice Address - State:NM
Practice Address - Zip Code:87571
Practice Address - Country:US
Practice Address - Phone:505-758-1203
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-01
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMPH00002361333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMPH00002361OtherPHARMACY LICENSE
NM4421900004Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER