MEDICARE: ADDISON DRUG

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	183500000X	Pharmacist	PH00001147	NM

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	3202253	OTHER	NM	NCPDP NUMBER

General Provider Information

NPI Number	:	1841219128
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ADDISON DRUG

Provider Business Mailing Address
First Line	:	PO BOX 550
Second Line	:	127 E. SUMNER AVENUE
City	:	FORT SUMNER
State	:	NM
Zip	:	88119-0550
Country	:	US
Telephone Number	:	505-355-2211
Fax Number	:	505-355-7816

Provider Business Practice Location Address
First Line	:	323 SUMNER AVE
Second Line	:
City	:	FORT SUMNER
State	:	NM
Zip	:	88119-0550
Country	:	US
Telephone Number	:	505-355-2211
Fax Number	:	505-355-7816

Authorized Official
Title or Position	:	OWNER
Name	:	MR. ROBERT M ADDISON
Credential	:	RPH
Telephone Number	:	505-355-2211

Provider Enumeration Date	:	07/18/2006
Last Update Date	:	08/22/2020

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Directions to “ADDISON DRUG ” Practice Location

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