Basic Information
| Provider Information | |||||||||
| NPI: | 1265767800 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | NOR-LEA HOSPITAL DISTRICT | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | NOR-LEA GENERAL HOSPITAL | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 1600 N MAIN AVE | ||||||||
| Address2: | |||||||||
| City: | LOVINGTON | ||||||||
| State: | NM | ||||||||
| PostalCode: | 882602813 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5753966611 | ||||||||
| FaxNumber: | 5753965971 | ||||||||
| Practice Location | |||||||||
| Address1: | 1600 N MAIN AVE | ||||||||
| Address2: | |||||||||
| City: | LOVINGTON | ||||||||
| State: | NM | ||||||||
| PostalCode: | 882602813 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5753966611 | ||||||||
| FaxNumber: | 5753965971 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/15/2009 | ||||||||
| LastUpdateDate: | 11/24/2009 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | SHAW | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 5753966611 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3336I0012X | N | Suppliers | Pharmacy | Institutional Pharmacy | 333600000X | PH000002159 | NM | Y | Suppliers | Pharmacy |
ID Information
| ID | Type | State | Issuer | Description | 3211923 | 01 | NCPDP PROVIDER IDENTIFICATION NUMBER | OTHER |