Healthcare Provider Details

I. General information

NPI: 1720208929
Provider Name (Legal Business Name): BEN J PEACOCK PHARMACIST
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/27/2007
Last Update Date: 11/29/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

US HWY 491 NORTH
SHIPROCK NM
87420
US

IV. Provider business mailing address

PO BOX 160
SHIPROCK NM
87420-0160
US

V. Phone/Fax

Practice location:
  • Phone: 505-368-7269
  • Fax: 505-368-7262
Mailing address:
  • Phone: 505-368-7269
  • Fax: 505-368-7262

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number18305
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberRP00007253
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: