Provider Demographics
NPI:1750403762
Name:KIVA PHARMACY INC.
Entity type:Organization
Organization Name:KIVA PHARMACY INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF PHARMACIST
Authorized Official - Prefix:MR
Authorized Official - First Name:TOM
Authorized Official - Middle Name:K
Authorized Official - Last Name:WHITE
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:505-982-9550
Mailing Address - Street 1:159 PASEO DE PERALTA
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87501-1857
Mailing Address - Country:US
Mailing Address - Phone:505-982-9550
Mailing Address - Fax:505-982-1576
Practice Address - Street 1:159 PASEO DE PERALTA
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87501-1857
Practice Address - Country:US
Practice Address - Phone:505-982-9550
Practice Address - Fax:505-982-1576
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-03
Last Update Date:2009-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMPH000017313336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy