Healthcare Provider Details

I. General information

NPI: 1174207492
Provider Name (Legal Business Name): EDGARDO RODRIGUEZ PHARMACY INTERN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/15/2023
Last Update Date: 02/05/2026
Certification Date: 02/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1096 S SAINT FRANCIS DR
SANTA FE NM
87505-1654
US

IV. Provider business mailing address

4701 N CHARLES ST
BALTIMORE MD
21210-2404
US

V. Phone/Fax

Practice location:
  • Phone: 505-982-9811
  • Fax:
Mailing address:
  • Phone: 787-975-9335
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberRP00010437
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: