Healthcare Provider Details

I. General information

NPI: 1518062926
Provider Name (Legal Business Name): RALEYS OF NEW MEXICO INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/13/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8100 VENTURA ST NE
ALBUQUERQUE NM
87122-1303
US

IV. Provider business mailing address

8100 VENTURA ST NE
ALBUQUERQUE NM
87122-1303
US

V. Phone/Fax

Practice location:
  • Phone: 505-822-8484
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License NumberPH00002797
License Number StateNM

VIII. Authorized Official

Name: FLINT PENDERGRAFT
Title or Position: VP PHARMACY AND HLI
Credential: PHARMD
Phone: 916-373-6146