Healthcare Provider Details

I. General information

NPI: 1750411096
Provider Name (Legal Business Name): WILFRED CHAVEZ PHRAMACIST
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/06/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

701 DALIES AVE
BELEN NM
87002-3617
US

IV. Provider business mailing address

701 DALIES AVE
BELEN NM
87002-3617
US

V. Phone/Fax

Practice location:
  • Phone: 505-864-7471
  • Fax: 505-864-6535
Mailing address:
  • Phone: 505-864-7471
  • Fax: 505-864-6535

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License NumberCS00208115
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: