Provider Demographics
NPI:1336547710
Name:STANFORD, OLIVER (RPH)
Entity Type:Individual
Prefix:
First Name:OLIVER
Middle Name:
Last Name:STANFORD
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 1:36 E CHILI LINE RD
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87508-1387
Mailing Address - Country:US
Mailing Address - Phone:303-906-3934
Mailing Address - Fax:
Practice Address - Street 1:1691 GALISTEO ST
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505-4780
Practice Address - Country:US
Practice Address - Phone:505-988-9797
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-12-16
Last Update Date:2014-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM7891183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist