Provider Demographics
NPI:1205953155
Name:BEBOUT, DONALD (RPH)
Entity type:Individual
Prefix:
First Name:DONALD
Middle Name:
Last Name:BEBOUT
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 1:5701 HERRERA DRIVE
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87507
Mailing Address - Country:US
Mailing Address - Phone:505-424-9166
Mailing Address - Fax:
Practice Address - Street 1:5701 HERRERA DRIVE
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87507
Practice Address - Country:US
Practice Address - Phone:505-424-9166
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-24
Last Update Date:2015-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA015439183500000X
IN26014461A183500000X
NMRP00007739183500000X
GARPH015439183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist