Provider Demographics
NPI:1275647992
Name:AYCOCK, CECIL MACK (PHARM D)
Entity Type:Individual
Prefix:DR
First Name:CECIL
Middle Name:MACK
Last Name:AYCOCK
Suffix:
Gender:M
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:516 NIZHONI BLVD
Mailing Address - Street 2:
Mailing Address - City:GALLUP
Mailing Address - State:NM
Mailing Address - Zip Code:87301-5748
Mailing Address - Country:US
Mailing Address - Phone:505-722-1211
Mailing Address - Fax:505-726-8621
Practice Address - Street 1:516 NIZHONI BLVD
Practice Address - Street 2:GALLUP INDIAN MEDICAL CENTER - PHARMACY
Practice Address - City:GALLUP
Practice Address - State:NM
Practice Address - Zip Code:87301-5748
Practice Address - Country:US
Practice Address - Phone:505-722-1211
Practice Address - Fax:505-726-8621
Is Sole Proprietor?:No
Enumeration Date:2006-08-19
Last Update Date:2008-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN9502183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist