Healthcare Provider Details

I. General information

NPI: 1942615570
Provider Name (Legal Business Name): PRESBYTERIAN HEALTHCARE SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/23/2014
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2401 W. 21ST ST
CLOVIS NM
88101
US

IV. Provider business mailing address

2401 W. 21ST ST
CLOVIS NM
88101
US

V. Phone/Fax

Practice location:
  • Phone: 575-769-7680
  • Fax: 575-769-7156
Mailing address:
  • Phone: 575-769-7541
  • Fax: 575-769-7156

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License NumberPH00003710
License Number StateNM

VIII. Authorized Official

Name: KIMBERLY POLAND
Title or Position: PROVIDER ENROLLMENT MANAGER
Credential:
Phone: 505-923-5355