Healthcare Provider Details

I. General information

NPI: 1922308675
Provider Name (Legal Business Name): MAHMOOD R HURAB PHC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/28/2010
Last Update Date: 10/28/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 W LISA DR
CHAPARRAL NM
88081-7458
US

IV. Provider business mailing address

111 W LISA DR
CHAPARRAL NM
88081-7458
US

V. Phone/Fax

Practice location:
  • Phone: 575-824-8211
  • Fax: 575-824-8208
Mailing address:
  • Phone: 575-824-8211
  • Fax: 575-824-8208

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835P0018X
TaxonomyPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
License NumberPC00000180
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: