Healthcare Provider Details

I. General information

NPI: 1124894209
Provider Name (Legal Business Name): ELYAS SAMADI
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/29/2023
Last Update Date: 11/29/2023
Certification Date: 11/29/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5850 EUBANK BLVD NE
ALBUQUERQUE NM
87111-6132
US

IV. Provider business mailing address

8419 ESTATES DR NE
ALBUQUERQUE NM
87122-2644
US

V. Phone/Fax

Practice location:
  • Phone: 505-299-7621
  • Fax:
Mailing address:
  • Phone: 505-450-6088
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835P0018X
TaxonomyPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
License NumberRP00010058
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: