Healthcare Provider Details

I. General information

NPI: 1639362783
Provider Name (Legal Business Name): ANDREW J BUSTOS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/22/2007
Last Update Date: 08/22/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2709 PAN AMERICAN FWY NE STE G
ALBUQUERQUE NM
87107-1650
US

IV. Provider business mailing address

4031 BRYAN AVE NW
ALBUQUERQUE NM
87114-5215
US

V. Phone/Fax

Practice location:
  • Phone: 505-341-4739
  • Fax: 505-341-4745
Mailing address:
  • Phone: 505-343-9831
  • Fax: 505-341-4745

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberRP00006146
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: