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General NPI Number Information
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NPI Number | 1295944072
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Entity Type | Individual
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Provider Name | MR. JACKIE ROSS SIMMONS
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Gender | Male
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Dates
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Enumeration Date | 05/21/2007
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 622 PASEO DEL PUEBLO SUR STE A 5401 NDCBU
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City | TAOS
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State | NM
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Zip | 87571-5101
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Country | US
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Telephone | 505-758-3342
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Fax |
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Provider Business Mailing Address
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Address Line | 26058 TAOS CANYON, HWY 64 HC 71 BOX 77
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City | TAOS
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State | NM
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Zip | 87571-9501
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Country | US
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Telephone | 505-758-8309
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 183500000X
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Taxonomy Name | Pharmacist
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License Number | 6447
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License Number State | NM
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