Healthcare Provider Details

I. General information

NPI: 1881727873
Provider Name (Legal Business Name): ACOMA CANONCITO LAGUNA PHARMACY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/13/2007
Last Update Date: 02/10/2025
Certification Date: 02/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

80 B VETERANS BLVD
ACOMA NM
87034-8703
US

IV. Provider business mailing address

PO BOX 95475
CLEVELAND OH
44101-0033
US

V. Phone/Fax

Practice location:
  • Phone: 505-552-5393
  • Fax: 505-552-5484
Mailing address:
  • Phone: 505-552-5394
  • Fax: 505-552-5464

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code3336C0002X
TaxonomyClinic Pharmacy
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3336I0012X
TaxonomyInstitutional Pharmacy
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code3336S0011X
TaxonomySpecialty Pharmacy
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code332800000X
TaxonomyIndian Health Service/Tribal/Urban Indian Health (I/T/U) Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: INNA VOINICH
Title or Position: CHIEF PHARMACIST
Credential: PHARMD
Phone: 505-552-5393