Healthcare Provider Details

I. General information

NPI: 1386276160
Provider Name (Legal Business Name): CORRALES PHARMACY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/10/2020
Last Update Date: 02/10/2020
Certification Date: 02/10/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

221 STATE HIGHWAY 165 # A4 A4
PLACITAS NM
87043-9514
US

IV. Provider business mailing address

221 STATE HIGHWAY 165 # A4 A4
PLACITAS NM
87043-9514
US

V. Phone/Fax

Practice location:
  • Phone: 505-480-6327
  • Fax:
Mailing address:
  • Phone: 505-480-6327
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0002X
TaxonomyClinic Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: DR. MIKE LEE GALLEGOS
Title or Position: PIC OWNER
Credential: PHARMD, PC
Phone: 505-480-6327