Healthcare Provider Details

I. General information

NPI: 1437621943
Provider Name (Legal Business Name): LLOYD'S WATER PAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/21/2018
Last Update Date: 12/21/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

622 WEST FIRST STREET SOON OTHER AT OTHER : 8700 EAST FOURTH STREET
DEMING NM
88030
US

IV. Provider business mailing address

702 W 1ST ST
DEMING NM
88030-3012
US

V. Phone/Fax

Practice location:
  • Phone: 575-202-6110
  • Fax:
Mailing address:
  • Phone: 575-202-6110
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835N1003X
TaxonomyNutrition Support Pharmacist
License Number
License Number State

VIII. Authorized Official

Name: BILLY L EDWARDS I
Title or Position: CEO
Credential:
Phone: 575-202-6110