Provider Demographics
NPI:1649667890
Name:MASCARENAS, ERNESTO (RPH)
Entity type:Individual
Prefix:MR
First Name:ERNESTO
Middle Name:
Last Name:MASCARENAS
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:MR
Other - First Name:ERNESTO
Other - Middle Name:L
Other - Last Name:MASCARENAS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:RPH
Mailing Address - Street 1:501 OLD SANTA FE TRL
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87505-0306
Mailing Address - Country:US
Mailing Address - Phone:505-455-2256
Mailing Address - Fax:505-455-7929
Practice Address - Street 1:501 OLD SANTA FE TRL
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505-0306
Practice Address - Country:US
Practice Address - Phone:505-455-2256
Practice Address - Fax:505-455-7929
Is Sole Proprietor?:No
Enumeration Date:2015-04-24
Last Update Date:2017-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM4536183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist