Basic Information
| Provider Information | |||||||||
| NPI: | 1336453562 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | AVALOS | ||||||||
| FirstName: | IRMA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | RPH | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | ROBLES | ||||||||
| OtherFirstName: | IRMA | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1209 UNIVERSITY BLVD NE | ||||||||
| Address2: | |||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871021727 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5052724400 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1209 UNIVERSITY BLVD NE | ||||||||
| Address2: | |||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871021727 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5052207152 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/29/2010 | ||||||||
| LastUpdateDate: | 04/27/2012 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 183500000X | RPH00006368 | NM | N | Pharmacy Service Providers | Pharmacist | 1835P0018X | PC00000198 | NM | Y | Pharmacy Service Providers | Pharmacist | Pharmacist Clinician (PhC)/ Clinical Pharmacy Specialist |
No ID Information.