Provider Demographics
NPI:1881727873
Name:ACOMA CANONCITO LAGUNA PHARMACY
Entity type:Organization
Organization Name:ACOMA CANONCITO LAGUNA PHARMACY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CHIEF PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:INNA
Authorized Official - Middle Name:
Authorized Official - Last Name:VOINICH
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:505-552-5393
Mailing Address - Street 1:PO BOX 95475
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44101-0033
Mailing Address - Country:US
Mailing Address - Phone:505-552-5394
Mailing Address - Fax:505-552-5464
Practice Address - Street 1:80 B VETERANS BLVD
Practice Address - Street 2:
Practice Address - City:ACOMA
Practice Address - State:NM
Practice Address - Zip Code:87034-8703
Practice Address - Country:US
Practice Address - Phone:505-552-5393
Practice Address - Fax:505-552-5484
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-13
Last Update Date:2025-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332800000XSuppliersIndian Health Service/Tribal/Urban Indian Health (I/T/U) Pharmacy
No3336C0002XSuppliersPharmacyClinic Pharmacy
No3336I0012XSuppliersPharmacyInstitutional Pharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMH3451Medicaid
3209245OtherNCPDP PROVIDER IDENTIFICATION NUMBER
3209245OtherNCPDP PROVIDER IDENTIFICATION NUMBER