Healthcare Provider Details

I. General information

NPI: 1659973873
Provider Name (Legal Business Name): MARISSA CHACON PHARMD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/12/2020
Last Update Date: 11/12/2020
Certification Date: 11/12/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1501 SAN PEDRO DR SE STE 119
ALBUQUERQUE NM
87108-5180
US

IV. Provider business mailing address

1501 SAN PEDRO DR SE STE 119
ALBUQUERQUE NM
87108-5180
US

V. Phone/Fax

Practice location:
  • Phone: 505-265-1711
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835P1300X
TaxonomyPsychiatric Pharmacist
License NumberRP00008792
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: