Healthcare Provider Details

I. General information

NPI: 1366522666
Provider Name (Legal Business Name): CHARLES EDWARD MAHAN III PHARMD, PHC, RPH
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/17/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 DR MARTIN LUTHER KING JR AVE NE
ALBUQUERQUE NM
87102-3619
US

IV. Provider business mailing address

13215 RUSSIAN SAGE CT NE
ALBUQUERQUE NM
87111-8270
US

V. Phone/Fax

Practice location:
  • Phone: 505-727-8877
  • Fax: 505-727-9269
Mailing address:
  • Phone: 505-821-0383
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835P1200X
TaxonomyPharmacotherapy Pharmacist
License NumberRP6003, PC107
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: