Healthcare Provider Details

I. General information

NPI: 1184377269
Provider Name (Legal Business Name): ERNESTO F MARTINEZ
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/30/2022
Last Update Date: 01/30/2022
Certification Date: 01/30/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

233 S NEW YORK AVE
ALAMOGORDO NM
88310-6530
US

IV. Provider business mailing address

233 S NEW YORK AVE
ALAMOGORDO NM
88310-6530
US

V. Phone/Fax

Practice location:
  • Phone: 575-434-5345
  • Fax:
Mailing address:
  • Phone: 575-434-5345
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183700000X
TaxonomyPharmacy Technician
License NumberPT00014109
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: