Provider Demographics
NPI:1891963922
Name:NELSON, ROBERT MARK SR (RPH)
Entity Type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:MARK
Last Name:NELSON
Suffix:SR
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5604 FAIR OAK TRL NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87109-3209
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8011 VENTURA ST NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87109-6429
Practice Address - Country:US
Practice Address - Phone:505-217-2860
Practice Address - Fax:505-217-2866
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-12
Last Update Date:2011-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMRP00004158183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist