Healthcare Provider Details

I. General information

NPI: 1760852271
Provider Name (Legal Business Name): ABQ BESTCARE PHARMACY 2 LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/28/2015
Last Update Date: 03/21/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5400 GIBSON BLVD SE (GIBSON MEDICAL CENTER PHARMACY)
ALBUQUERQUE NM
87108-4729
US

IV. Provider business mailing address

5400 GIBSON BLVD SE (GIBSON MEDICAL CENTER PHARMACY)
ALBUQUERQUE NM
87108-4729
US

V. Phone/Fax

Practice location:
  • Phone: 505-268-2030
  • Fax: 505-268-2022
Mailing address:
  • Phone: 505-268-2030
  • Fax: 505-268-2022

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code3336S0011X
TaxonomySpecialty Pharmacy
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License NumberPH00004053
License Number StateNM

VIII. Authorized Official

Name: RANJITHA PALLAPOTHU
Title or Position: MANAGING MEMBER
Credential:
Phone: 214-675-2012