Healthcare Provider Details

I. General information

NPI: 1740607738
Provider Name (Legal Business Name): JAY SIMON RPH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/27/2014
Last Update Date: 03/27/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2502 MARBLE NE RM B-48
ALBUQUERQUE NM
87131-0001
US

IV. Provider business mailing address

53 ROCK RIDGE CT NE
ALBUQUERQUE NM
87122-2023
US

V. Phone/Fax

Practice location:
  • Phone: 505-925-0748
  • Fax:
Mailing address:
  • Phone: 505-306-6742
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835N0905X
TaxonomyNuclear Pharmacist
License NumberRP00008035
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: