Provider Demographics
NPI:1265727820
Name:VIRAMONTES, PABLO IV (RPH)
Entity type:Individual
Prefix:MR
First Name:PABLO
Middle Name:
Last Name:VIRAMONTES
Suffix:IV
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 1:4900 E MAIN ST
Mailing Address - Street 2:T-0952
Mailing Address - City:FARMINGTON
Mailing Address - State:NM
Mailing Address - Zip Code:87402-8658
Mailing Address - Country:US
Mailing Address - Phone:505-327-3555
Mailing Address - Fax:
Practice Address - Street 1:4900 E MAIN ST
Practice Address - Street 2:T-0952
Practice Address - City:FARMINGTON
Practice Address - State:NM
Practice Address - Zip Code:87402-8658
Practice Address - Country:US
Practice Address - Phone:505-327-3555
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-12
Last Update Date:2011-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMRP6201183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM16475810Medicaid