Healthcare Provider Details

I. General information

NPI: 1679046122
Provider Name (Legal Business Name): JOHNSPHARMACYABQ LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/08/2019
Last Update Date: 10/15/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9134 CENTRAL AVE SE
ALBUQUERQUE NM
87123-2510
US

IV. Provider business mailing address

9134 CENTRAL AVE SE
ALBUQUERQUE NM
87123-2510
US

V. Phone/Fax

Practice location:
  • Phone: 505-299-6169
  • Fax: 505-296-8859
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: JOHN MA
Title or Position: CEO
Credential:
Phone: 505-299-6169