Healthcare Provider Details

I. General information

NPI: 1093610362
Provider Name (Legal Business Name): KENNETH SANTISTEVAN JR.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/08/2026
Last Update Date: 10/08/2026
Certification Date: 10/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

712 CATALINA CT
LAS VEGAS NM
87701-4929
US

IV. Provider business mailing address

712 CATALINA CT
LAS VEGAS NM
87701-4929
US

V. Phone/Fax

Practice location:
  • Phone: 505-426-5181
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberRP00010530
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: