Provider Demographics
NPI:1063427607
Name:UNM STUDENT HEALTH CENTER PHARMACY
Entity type:Organization
Organization Name:UNM STUDENT HEALTH CENTER PHARMACY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHARMACY MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:HERMOSILLO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:505-277-4469
Mailing Address - Street 1:I UNIV OF NEW MEXICO MSC06 3870
Mailing Address - Street 2:BLDG 73 RM 206, MSC06-3870
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87131-0001
Mailing Address - Country:US
Mailing Address - Phone:505-277-6306
Mailing Address - Fax:505-277-0286
Practice Address - Street 1:I UNIV OF NEW MEXICO MSC06 3870
Practice Address - Street 2:BLDG 73 RM 206
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87131-0001
Practice Address - Country:US
Practice Address - Phone:505-277-6306
Practice Address - Fax:505-277-0286
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-30
Last Update Date:2018-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
NMPH000021663336C0003X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2056415OtherPK
NM59682Medicaid