Healthcare Provider Details

I. General information

NPI: 1922838465
Provider Name (Legal Business Name): MICHAEL'S PRESCRIPTION CORNER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/07/2024
Last Update Date: 08/07/2024
Certification Date: 07/31/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

310 CONTINENTAL SUITE 100
JAL NM
88252
US

IV. Provider business mailing address

PO BOX 933
JAL NM
88252-0933
US

V. Phone/Fax

Practice location:
  • Phone: 575-397-2311
  • Fax:
Mailing address:
  • Phone: 575-397-2311
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: MICHAEL C RABURN
Title or Position: OWNER
Credential: RPH
Phone: 575-396-2311