Provider Demographics
NPI:1750411096
Name:CHAVEZ, WILFRED (PHRAMACIST)
Entity type:Individual
Prefix:
First Name:WILFRED
Middle Name:
Last Name:CHAVEZ
Suffix:
Gender:M
Credentials:PHRAMACIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:701 DALIES AVE
Mailing Address - Street 2:
Mailing Address - City:BELEN
Mailing Address - State:NM
Mailing Address - Zip Code:87002-3617
Mailing Address - Country:US
Mailing Address - Phone:505-864-7471
Mailing Address - Fax:505-864-6535
Practice Address - Street 1:701 DALIES AVE
Practice Address - Street 2:
Practice Address - City:BELEN
Practice Address - State:NM
Practice Address - Zip Code:87002-3617
Practice Address - Country:US
Practice Address - Phone:505-864-7471
Practice Address - Fax:505-864-6535
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMCS002081153336C0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMCS00208115OtherLICENSE NUMBER