MEDICARE: RALEYS OF NEW MEXICO INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	333600000X	Pharmacy	PH00002743	NM
2	3336C0003X	Community/Retail Pharmacy

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	3211050	OTHER		OTHER ID NUMBER-COMMERCIAL NUMBER

General Provider Information

NPI Number	:	1902916687
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RALEYS OF NEW MEXICO INC

Provider Business Mailing Address
First Line	:	2910 JUAN TABO BLVD NE
Second Line	:
City	:	ALBUQUERQUE
State	:	NM
Zip	:	87112-1828
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2910 JUAN TABO BLVD NE
Second Line	:
City	:	ALBUQUERQUE
State	:	NM
Zip	:	87112-1828
Country	:	US
Telephone Number	:	505-299-8600
Fax Number	:	505-299-8609

Authorized Official
Title or Position	:	VP PHARMACY AND HLI
Name	:	FLINT PENDERGRAFT
Credential	:	PHARMD
Telephone Number	:	916-373-6146

Provider Enumeration Date	:	08/30/2006
Last Update Date	:	09/11/2025

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