Healthcare Provider Details

I. General information

NPI: 1508080987
Provider Name (Legal Business Name): THOREAU HEALTH STATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/13/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

HWY 371 ROUTE 9
CROWNPOINT NM
87313-0358
US

IV. Provider business mailing address

PO BOX 358
CROWNPOINT NM
87313-0358
US

V. Phone/Fax

Practice location:
  • Phone: 505-786-6344
  • Fax: 505-786-6440
Mailing address:
  • Phone: 505-786-6344
  • Fax: 505-786-6440

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0002X
TaxonomyClinic Pharmacy
License NumberAU4720846
License Number StateNM

VIII. Authorized Official

Name: STACY WILLIAMS
Title or Position: CHIEF PHARMACIST
Credential:
Phone: 505-786-6344