1285924803 NPI number — COMPLETE CARE PHARMACY LLC

Table of content: (NPI 1285924803)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1285924803 NPI number — COMPLETE CARE PHARMACY LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
COMPLETE CARE PHARMACY LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1285924803
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/13/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4940 CORRALES RD
Provider Second Line Business Mailing Address:
SUITE 200
Provider Business Mailing Address City Name:
CORRALES
Provider Business Mailing Address State Name:
NM
Provider Business Mailing Address Postal Code:
87048-8673
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
505-897-3784
Provider Business Mailing Address Fax Number:
505-897-3795

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4940 CORRALES RD
Provider Second Line Business Practice Location Address:
SUITE 200
Provider Business Practice Location Address City Name:
CORRALES
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
87048-8673
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
505-897-3784
Provider Business Practice Location Address Fax Number:
505-897-3795
Provider Enumeration Date:
04/15/2011

Additional Information

Authorized Official

Authorized Official Last Name:
GALLEGOS
Authorized Official First Name:
MIKE
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER,PIC,AO
Authorized Official Telephone Number:
505-897-3784

Provider Taxonomy Codes

  • Taxonomy code: 3336C0003X , with the licence number:  PH00004048 , registered in the state of NM ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 3336C0004X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 2142883 . This is a "PK" identifier . This identifiers is of the category "OTHER".
  • Identifier: 96472031 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".




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