=====================================================
General NPI Number Information
=====================================================
NPI Number | 1780677153
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CHRISTINE E. MARTINEZ-VIGIL PHC,RPH
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/31/2005
-----------------------------------------------------
Last Update Date | 07/09/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2010 INDUSTRIAL PARK RD
-----------------------------------------------------
City | ESPANOLA
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87532-3600
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 505-753-7218
-----------------------------------------------------
Fax | 505-753-5815
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 538 N PASEO DE ONATE P.O. BOX 158
-----------------------------------------------------
City | ESPANOLA
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87532-2618
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 505-753-7218
-----------------------------------------------------
Fax | 505-753-5815
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | RP00005496
-----------------------------------------------------
License Number State | NM
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | PC00000038
-----------------------------------------------------
License Number State | NM
-----------------------------------------------------