Healthcare Provider Details

I. General information

NPI: 1740663293
Provider Name (Legal Business Name): ABQ BESTCARE PHARMACY -1 LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/01/2015
Last Update Date: 07/04/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2929 COORS BLVD NW STE 110
ALBUQUERQUE NM
87120-1272
US

IV. Provider business mailing address

10328 MARCHANT LN
IRVING TX
75063-4505
US

V. Phone/Fax

Practice location:
  • Phone: 917-769-8014
  • Fax:
Mailing address:
  • Phone: 917-769-8014
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License NumberPH00004001
License Number StateNM

VIII. Authorized Official

Name: MR. PREM KALIDINDI
Title or Position: MANAGER
Credential: RPH
Phone: 917-769-8014