Provider Demographics
NPI:1962589077
Name:BASTIAN, GAIL M (PHC)
Entity type:Individual
Prefix:
First Name:GAIL
Middle Name:M
Last Name:BASTIAN
Suffix:
Gender:F
Credentials:PHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:157 ANYA RD
Mailing Address - Street 2:
Mailing Address - City:CORRALES
Mailing Address - State:NM
Mailing Address - Zip Code:87048-8582
Mailing Address - Country:US
Mailing Address - Phone:505-265-1711
Mailing Address - Fax:
Practice Address - Street 1:454 SAINT MICHAELS DR
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505-7602
Practice Address - Country:US
Practice Address - Phone:505-303-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2020-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMRP00006061183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist