Healthcare Provider Details

I. General information

NPI: 1750403762
Provider Name (Legal Business Name): KIVA PHARMACY INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/03/2007
Last Update Date: 12/18/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

159 PASEO DE PERALTA
SANTA FE NM
87501-1857
US

IV. Provider business mailing address

159 PASEO DE PERALTA
SANTA FE NM
87501-1857
US

V. Phone/Fax

Practice location:
  • Phone: 505-982-9550
  • Fax: 505-982-1576
Mailing address:
  • Phone: 505-982-9550
  • Fax: 505-982-1576

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License NumberPH00001731
License Number StateNM

VIII. Authorized Official

Name: MR. TOM K. WHITE
Title or Position: CHIEF PHARMACIST
Credential: RPH.
Phone: 505-982-9550