Provider Demographics
NPI:1730251521
Name:MEDICAL ARTS PHARMACY INC
Entity type:Organization
Organization Name:MEDICAL ARTS PHARMACY INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHRM
Authorized Official - Prefix:
Authorized Official - First Name:HAL
Authorized Official - Middle Name:
Authorized Official - Last Name:SIMS
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:575-437-5530
Mailing Address - Street 1:1301 10TH ST
Mailing Address - Street 2:
Mailing Address - City:ALAMOGORDO
Mailing Address - State:NM
Mailing Address - Zip Code:88310-5804
Mailing Address - Country:US
Mailing Address - Phone:505-437-5530
Mailing Address - Fax:505-434-3237
Practice Address - Street 1:1301 10TH ST
Practice Address - Street 2:
Practice Address - City:ALAMOGORDO
Practice Address - State:NM
Practice Address - Zip Code:88310-5804
Practice Address - Country:US
Practice Address - Phone:575-437-5530
Practice Address - Fax:575-434-3237
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-15
Last Update Date:2011-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
NMPH000015563336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM61754Medicaid
3203952OtherNCPDP PROVIDER IDENTIFICATION NUMBER
0812720001Medicare NSC