Provider Demographics
NPI:1841612918
Name:PADILLA, JEREMIAS
Entity Type:Individual
Prefix:
First Name:JEREMIAS
Middle Name:
Last Name:PADILLA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:315 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BELEN
Mailing Address - State:NM
Mailing Address - Zip Code:87002-3715
Mailing Address - Country:US
Mailing Address - Phone:505-864-2083
Mailing Address - Fax:
Practice Address - Street 1:315 N MAIN ST
Practice Address - Street 2:
Practice Address - City:BELEN
Practice Address - State:NM
Practice Address - Zip Code:87002-3715
Practice Address - Country:US
Practice Address - Phone:505-864-2083
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-01-09
Last Update Date:2014-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMRP00007217183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist