Provider Demographics
NPI:1942615570
Name:PRESBYTERIAN HEALTHCARE SERVICES
Entity Type:Organization
Organization Name:PRESBYTERIAN HEALTHCARE SERVICES
Other - Org Name:PLAINS REGIONAL MEDICAL CENTER PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PROVIDER ENROLLMENT MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:
Authorized Official - Last Name:POLAND
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:505-923-5355
Mailing Address - Street 1:2401 W. 21ST ST
Mailing Address - Street 2:
Mailing Address - City:CLOVIS
Mailing Address - State:NM
Mailing Address - Zip Code:88101
Mailing Address - Country:US
Mailing Address - Phone:575-769-7541
Mailing Address - Fax:575-769-7156
Practice Address - Street 1:2401 W. 21ST ST
Practice Address - Street 2:
Practice Address - City:CLOVIS
Practice Address - State:NM
Practice Address - Zip Code:88101
Practice Address - Country:US
Practice Address - Phone:575-769-7680
Practice Address - Fax:575-769-7156
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PLAINS REGIONAL MEDICAL CENTER PHARMACY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-06-23
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMPH000037103336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM47438363Medicaid
NM47438363Medicaid