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General NPI Number Information
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NPI Number | 1750403762
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Entity Type | Organization
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Legal Business Name | KIVA PHARMACY INC.
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Dates
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Enumeration Date | 04/03/2007
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Last Update Date | 12/18/2009
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Provider Practice Location Address
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Address Line | 159 PASEO DE PERALTA
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City | SANTA FE
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State | NM
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Zip | 87501-1857
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Country | US
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Telephone | 505-982-9550
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Fax | 505-982-1576
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Provider Business Mailing Address
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Address Line | 159 PASEO DE PERALTA
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City | SANTA FE
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State | NM
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Zip | 87501-1857
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Country | US
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Telephone | 505-982-9550
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Fax | 505-982-1576
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Authorized Official
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Title or Position | CHIEF PHARMACIST
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Name | MR. TOM K. WHITE
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Credential | RPH.
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Telephone | 505-982-9550
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 3336C0003X
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Taxonomy Name | Community/Retail Pharmacy
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License Number | PH00001731
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License Number State | NM
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