Healthcare Provider Details

I. General information

NPI: 1306861166
Provider Name (Legal Business Name): CHARLES NMI VANDIVER R.PH., PH.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/13/2006
Last Update Date: 03/07/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1422 PASEO DE PERALTA
SANTA FE NM
87501-4391
US

IV. Provider business mailing address

PO BOX 307 11 PRESTON TRAIL
ANGEL FIRE NM
87710-0307
US

V. Phone/Fax

Practice location:
  • Phone: 505-289-3291
  • Fax: 505-289-3648
Mailing address:
  • Phone: 505-377-2548
  • Fax: 505-377-2548

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835P1200X
TaxonomyPharmacotherapy Pharmacist
License NumberPC00000033
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: