1720140569 NPI number — WELLBORN PHARMACY, INC

Table of content: (NPI 1720140569)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1720140569 NPI number — WELLBORN PHARMACY, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WELLBORN PHARMACY, INC
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:
1720140569
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/20/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 985
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TUCUMCARI
Provider Business Mailing Address State Name:
NM
Provider Business Mailing Address Postal Code:
88401-0985
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
575-461-2784
Provider Business Mailing Address Fax Number:
575-461-2994

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1923 S 1ST ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TUCUMCARI
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
88401-3826
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
575-461-2784
Provider Business Practice Location Address Fax Number:
575-461-2994
Provider Enumeration Date:
12/15/2006

Additional Information

Authorized Official

Authorized Official Last Name:
WILSON
Authorized Official First Name:
BRIAN
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER / PRESIDENT
Authorized Official Telephone Number:
575-461-2784

Provider Taxonomy Codes

  • Taxonomy code: 333600000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0003X , with the licence number: PH00003107 , registered in the state of NM ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 2122816 . This is a "PK" identifier . This identifiers is of the category "OTHER".
  • Identifier: 56903 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".




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