Healthcare Provider Details

I. General information

NPI: 1801622725
Provider Name (Legal Business Name): ROBERT BACA RPH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/09/2024
Last Update Date: 09/09/2024
Certification Date: 09/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4700 4TH ST NW
ALBUQUERQUE NM
87107-3902
US

IV. Provider business mailing address

4500 NORMA DR NE
ALBUQUERQUE NM
87109-1736
US

V. Phone/Fax

Practice location:
  • Phone: 505-344-1390
  • Fax:
Mailing address:
  • Phone: 575-512-6939
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberRP00010215
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: