Provider Demographics
NPI:1386276160
Name:CORRALES PHARMACY INC
Entity type:Organization
Organization Name:CORRALES PHARMACY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PIC OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MIKE
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:GALLEGOS
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD, PC
Authorized Official - Phone:505-480-6327
Mailing Address - Street 1:221 STATE HIGHWAY 165 # A4
Mailing Address - Street 2:A4
Mailing Address - City:PLACITAS
Mailing Address - State:NM
Mailing Address - Zip Code:87043-9514
Mailing Address - Country:US
Mailing Address - Phone:505-480-6327
Mailing Address - Fax:
Practice Address - Street 1:221 STATE HIGHWAY 165 # A4
Practice Address - Street 2:A4
Practice Address - City:PLACITAS
Practice Address - State:NM
Practice Address - Zip Code:87043-9514
Practice Address - Country:US
Practice Address - Phone:505-480-6327
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CORRALES PHARMACY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2020-02-10
Last Update Date:2020-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0002XSuppliersPharmacyClinic Pharmacy