Healthcare Provider Details

I. General information

NPI: 1447483755
Provider Name (Legal Business Name): JERRY PADILLA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/02/2009
Last Update Date: 09/02/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2200 UNSER BLVD NW
ALBUQUERQUE NM
87120-3889
US

IV. Provider business mailing address

2200 UNSER BLVD NW
ALBUQUERQUE NM
87120-3889
US

V. Phone/Fax

Practice location:
  • Phone: 505-217-9940
  • Fax: 505-217-9996
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberRP00006085
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: