Provider Demographics
NPI:1386493096
Name:CARRUESCO, ROBERT PHILLIP
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:PHILLIP
Last Name:CARRUESCO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:87 CRAZY HORSE DR
Mailing Address - Street 2:
Mailing Address - City:DURANGO
Mailing Address - State:CO
Mailing Address - Zip Code:81301-3113
Mailing Address - Country:US
Mailing Address - Phone:970-422-2502
Mailing Address - Fax:
Practice Address - Street 1:87 CRAZY HORSE DR
Practice Address - Street 2:
Practice Address - City:DURANGO
Practice Address - State:CO
Practice Address - Zip Code:81301-3113
Practice Address - Country:US
Practice Address - Phone:970-422-2502
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-15
Last Update Date:2024-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMRP000078941835G0303X, 1835P0018X
NM000078941835G0303X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
No1835G0303XPharmacy Service ProvidersPharmacistGeriatric