Healthcare Provider Details

I. General information

NPI: 1649311374
Provider Name (Legal Business Name): MICHAEL'S PRESCRIPTION CORNER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/08/2007
Last Update Date: 03/18/2022
Certification Date: 03/18/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

123 W AVENUE A
LOVINGTON NM
88260-4211
US

IV. Provider business mailing address

123 W AVENUE A
LOVINGTON NM
88260-4211
US

V. Phone/Fax

Practice location:
  • Phone: 575-396-2311
  • Fax: 575-396-2321
Mailing address:
  • Phone: 575-396-2311
  • Fax: 575-396-2321

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License NumberCS00208480
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: MICHAEL RABURN
Title or Position: OWNER
Credential:
Phone: 505-396-2311