Provider Demographics
NPI:1942412986
Name:MOONEY, MARTIN PIERCE (RPH)
Entity Type:Individual
Prefix:MR
First Name:MARTIN
Middle Name:PIERCE
Last Name:MOONEY
Suffix:
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 1:1110 GOLF CLUB RD
Mailing Address - Street 2:
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88011
Mailing Address - Country:US
Mailing Address - Phone:619-980-8976
Mailing Address - Fax:505-521-3093
Practice Address - Street 1:1110 GOLF CLUB RD
Practice Address - Street 2:
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88011
Practice Address - Country:US
Practice Address - Phone:619-980-8976
Practice Address - Fax:505-521-3093
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM4258183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM4258OtherREG PHARMACIST LICENSE #