Healthcare Provider Details

I. General information

NPI: 1164773446
Provider Name (Legal Business Name): PHILLIP DANIEL O'BOURKE PHARM. D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/26/2012
Last Update Date: 09/26/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

516 E NIZHONI BLVD
GALLUP NM
87301-5748
US

IV. Provider business mailing address

500 LACIMA RD
GALLUP NM
87301-5739
US

V. Phone/Fax

Practice location:
  • Phone: 505-722-1000
  • Fax:
Mailing address:
  • Phone: 423-957-1649
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number0000036561
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: