Healthcare Provider Details

I. General information

NPI: 1386365948
Provider Name (Legal Business Name): LAWRENCE BENJAMIN CRUZ
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/12/2022
Last Update Date: 09/12/2022
Certification Date: 09/11/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2950 CENTRAL AVE SE
ALBUQUERQUE NM
87106-2263
US

IV. Provider business mailing address

2502 SERNA RD NW
ALBUQUERQUE NM
87104-2642
US

V. Phone/Fax

Practice location:
  • Phone: 505-262-1745
  • Fax:
Mailing address:
  • Phone: 505-697-9393
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberRP00009727
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: