Healthcare Provider Details

I. General information

NPI: 1073555330
Provider Name (Legal Business Name): MENAUL COMPOUNDING PHARMACY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/12/2006
Last Update Date: 11/29/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11417 MENAUL BLVD NE
ALBUQUERQUE NM
87112-1794
US

IV. Provider business mailing address

11417 MENAUL BLVD NE
ALBUQUERQUE NM
87112-1794
US

V. Phone/Fax

Practice location:
  • Phone: 505-291-1600
  • Fax: 505-291-1604
Mailing address:
  • Phone: 505-291-1600
  • Fax: 505-291-1604

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License NumberPH00002814
License Number StateNM

VIII. Authorized Official

Name: MOHAMMAD ZAMANIAN
Title or Position: PRESIDENT
Credential: RPH
Phone: 505-291-1600