Healthcare Provider Details

I. General information

NPI: 1043436595
Provider Name (Legal Business Name): MARK LARRAGOITE RPH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: G MARK LARRAGOITE RPH

II. Dates (important events)

Enumeration Date: 04/17/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2801 EUBANK BLVD NE STE A
ALBUQUERQUE NM
87112-1300
US

IV. Provider business mailing address

9409 OAKMONT RD NE
ALBUQUERQUE NM
87111-5822
US

V. Phone/Fax

Practice location:
  • Phone: 505-294-1597
  • Fax: 505-275-0340
Mailing address:
  • Phone: 505-857-9252
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberRP00004609
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: