Healthcare Provider Details

I. General information

NPI: 1649667890
Provider Name (Legal Business Name): ERNESTO MASCARENAS RPH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: ERNESTO L MASCARENAS RPH

II. Dates (important events)

Enumeration Date: 04/24/2015
Last Update Date: 02/17/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

501 OLD SANTA FE TRL
SANTA FE NM
87505-0306
US

IV. Provider business mailing address

501 OLD SANTA FE TRL
SANTA FE NM
87505-0306
US

V. Phone/Fax

Practice location:
  • Phone: 505-455-2256
  • Fax: 505-455-7929
Mailing address:
  • Phone: 505-455-2256
  • Fax: 505-455-7929

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number4536
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: