Healthcare Provider Details

I. General information

NPI: 1245648047
Provider Name (Legal Business Name): MARK NEWMAN R.PH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/25/2014
Last Update Date: 07/25/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1650 W MALONEY AVE
GALLUP NM
87301-3305
US

IV. Provider business mailing address

1650 W MALONEY AVE
GALLUP NM
87301-3305
US

V. Phone/Fax

Practice location:
  • Phone: 505-722-3823
  • Fax: 505-722-8853
Mailing address:
  • Phone: 505-722-3823
  • Fax: 505-722-8853

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberRP00005358
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: