Provider Demographics
NPI:1356348668
Name:YALE, EDWARD N (PHC)
Entity type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:N
Last Name:YALE
Suffix:
Gender:M
Credentials:PHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1708 BOULDER DR
Mailing Address - Street 2:
Mailing Address - City:GALLUP
Mailing Address - State:NM
Mailing Address - Zip Code:87301-5703
Mailing Address - Country:US
Mailing Address - Phone:505-722-3117
Mailing Address - Fax:
Practice Address - Street 1:516 NIZHONI BLVD
Practice Address - Street 2:
Practice Address - City:GALLUP
Practice Address - State:NM
Practice Address - Zip Code:87301-5748
Practice Address - Country:US
Practice Address - Phone:505-722-1185
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-06-30
Last Update Date:2008-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK115521835P1200X
NM67311835P1200X
NM1311835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
No1835P1200XPharmacy Service ProvidersPharmacistPharmacotherapy