Healthcare Provider Details

I. General information

NPI: 1902942519
Provider Name (Legal Business Name): DILLARD B IRBY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/30/2007
Last Update Date: 04/12/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

275 CENTRAL AVE # A
TULAROSA NM
88352-2009
US

IV. Provider business mailing address

275 CENTRAL AVE # A
TULAROSA NM
88352-2009
US

V. Phone/Fax

Practice location:
  • Phone: 575-585-2772
  • Fax: 575-585-2777
Mailing address:
  • Phone: 575-585-2772
  • Fax: 575-585-2777

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License NumberPH00001186
License Number StateNM

VIII. Authorized Official

Name: DILLARD IRBY
Title or Position: PHARMACIST AND OWNER
Credential: RPH
Phone: 575-585-2772