MEDICARE: ANDREW J BUSTOS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	183500000X	Pharmacist	RP00006146	NM

General Provider Information

NPI Number	:	1639362783
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ANDREW J BUSTOS

Provider Business Mailing Address
First Line	:	4031 BRYAN AVE NW
Second Line	:
City	:	ALBUQUERQUE
State	:	NM
Zip	:	87114-5215
Country	:	US
Telephone Number	:	505-343-9831
Fax Number	:	505-341-4745

Provider Business Practice Location Address
First Line	:	2709 PAN AMERICAN FWY NE STE G
Second Line	:
City	:	ALBUQUERQUE
State	:	NM
Zip	:	87107-1650
Country	:	US
Telephone Number	:	505-341-4739
Fax Number	:	505-341-4745

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/22/2007
Last Update Date	:	08/22/2007

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