Provider Demographics
NPI:1407191463
Name:PORTILLOS, ANDREW (RPH)
Entity type:Individual
Prefix:
First Name:ANDREW
Middle Name:
Last Name:PORTILLOS
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:338 OSUNA RD NW
Mailing Address - Street 2:
Mailing Address - City:LOS RANCHOS
Mailing Address - State:NM
Mailing Address - Zip Code:87107-6125
Mailing Address - Country:US
Mailing Address - Phone:505-345-3568
Mailing Address - Fax:505-345-1542
Practice Address - Street 1:338 OSUNA RD NW
Practice Address - Street 2:
Practice Address - City:LOS RANCHOS
Practice Address - State:NM
Practice Address - Zip Code:87107-6125
Practice Address - Country:US
Practice Address - Phone:505-345-3568
Practice Address - Fax:505-345-1542
Is Sole Proprietor?:No
Enumeration Date:2012-12-03
Last Update Date:2012-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM3822183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist