Healthcare Provider Details

I. General information

NPI: 1891816476
Provider Name (Legal Business Name): BRUCE ALEXANDER JACK RPH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/02/2007
Last Update Date: 08/29/2025
Certification Date: 08/29/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 CENTRAL AVE SE
ALBUQUERQUE NM
87106-4930
US

IV. Provider business mailing address

7416 SULKY DR NE
ALBUQUERQUE NM
87109-6804
US

V. Phone/Fax

Practice location:
  • Phone: 505-730-3355
  • Fax:
Mailing address:
  • Phone: 505-730-3355
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberRP00004151
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: