Provider Demographics
NPI:1902942519
Name:DILLARD B IRBY
Entity Type:Organization
Organization Name:DILLARD B IRBY
Other - Org Name:PROFESSIONAL PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACIST AND OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DILLARD
Authorized Official - Middle Name:
Authorized Official - Last Name:IRBY
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:575-585-2772
Mailing Address - Street 1:275 CENTRAL AVE # A
Mailing Address - Street 2:
Mailing Address - City:TULAROSA
Mailing Address - State:NM
Mailing Address - Zip Code:88352-2009
Mailing Address - Country:US
Mailing Address - Phone:575-585-2772
Mailing Address - Fax:575-585-2777
Practice Address - Street 1:275 CENTRAL AVE # A
Practice Address - Street 2:
Practice Address - City:TULAROSA
Practice Address - State:NM
Practice Address - Zip Code:88352-2009
Practice Address - Country:US
Practice Address - Phone:575-585-2772
Practice Address - Fax:575-585-2777
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-30
Last Update Date:2011-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
NMPH000011863336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
3207758OtherNCPDP PROVIDER IDENTIFICATION NUMBER
NM63255Medicaid