Provider Demographics
NPI:1396106670
Name:FT BAYARD MEDICAL CENTER DEPARTMENT OF HEALTH
Entity type:Organization
Organization Name:FT BAYARD MEDICAL CENTER DEPARTMENT OF HEALTH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF PHARMACY
Authorized Official - Prefix:MR
Authorized Official - First Name:JON
Authorized Official - Middle Name:MARK
Authorized Official - Last Name:BAILEY
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:575-537-8745
Mailing Address - Street 1:PO BOX 293
Mailing Address - Street 2:
Mailing Address - City:SANTA CLARA
Mailing Address - State:NM
Mailing Address - Zip Code:88026-0293
Mailing Address - Country:US
Mailing Address - Phone:575-537-8745
Mailing Address - Fax:575-537-8897
Practice Address - Street 1:41 FT. BAYARD RD.
Practice Address - Street 2:
Practice Address - City:SANTA CLARA
Practice Address - State:NM
Practice Address - Zip Code:88026
Practice Address - Country:US
Practice Address - Phone:575-537-8745
Practice Address - Fax:575-537-8897
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-14
Last Update Date:2016-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM3336L0003X3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA13343OtherIOWA BOARD OF PHARMACY LICENSE
NMRP00006632OtherNEW BOARD OF PHARMACY PHARMACIST
AZS005219OtherARIZONA BOARD OF PHARMACY