Provider Demographics
NPI:1306997424
Name:C JS PILL BOX INC
Entity type:Organization
Organization Name:C JS PILL BOX INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/RPH
Authorized Official - Prefix:
Authorized Official - First Name:TAWNIA
Authorized Official - Middle Name:
Authorized Official - Last Name:GAYLOR
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:575-356-4422
Mailing Address - Street 1:109 W 4TH ST
Mailing Address - Street 2:
Mailing Address - City:PORTALES
Mailing Address - State:NM
Mailing Address - Zip Code:88130-6306
Mailing Address - Country:US
Mailing Address - Phone:575-356-4422
Mailing Address - Fax:575-226-3026
Practice Address - Street 1:109 W 4TH ST
Practice Address - Street 2:
Practice Address - City:PORTALES
Practice Address - State:NM
Practice Address - Zip Code:88130-6306
Practice Address - Country:US
Practice Address - Phone:575-356-4422
Practice Address - Fax:575-226-3026
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-15
Last Update Date:2017-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
NMPH000029853336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM55277Medicaid
2056313OtherPK