Healthcare Provider Details

I. General information

NPI: 1073809661
Provider Name (Legal Business Name): CAROLE SIMON R.PH.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/22/2011
Last Update Date: 06/22/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9371 COORS BLVD NW
ALBUQUERQUE NM
87114-4005
US

IV. Provider business mailing address

9371 COORS BLVD NW
ALBUQUERQUE NM
87114-4005
US

V. Phone/Fax

Practice location:
  • Phone: 505-899-7731
  • Fax: 505-899-7731
Mailing address:
  • Phone: 505-899-7731
  • Fax: 505-899-7731

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number4154
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: