Healthcare Provider Details

I. General information

NPI: 1558775478
Provider Name (Legal Business Name): GEORGE MOYA III
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/18/2014
Last Update Date: 06/18/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2250 MAIN ST NW
LOS LUNAS NM
87031-4807
US

IV. Provider business mailing address

2250 MAIN ST NW
LOS LUNAS NM
87031-4807
US

V. Phone/Fax

Practice location:
  • Phone: 505-565-4622
  • Fax: 505-565-4625
Mailing address:
  • Phone: 505-565-4622
  • Fax: 505-565-4625

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number5356
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: