Healthcare Provider Details

I. General information

NPI: 1245239185
Provider Name (Legal Business Name): MJRX II LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/20/2005
Last Update Date: 01/29/2021
Certification Date: 01/29/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1445 WYOMING BLVD NE
ALBUQUERQUE NM
87112-3849
US

IV. Provider business mailing address

1445 WYOMING BLVD NE
ALBUQUERQUE NM
87112-3849
US

V. Phone/Fax

Practice location:
  • Phone: 505-299-4496
  • Fax: 505-299-7713
Mailing address:
  • Phone: 505-299-4496
  • Fax: 505-299-7713

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License NumberPH00004054
License Number StateNM

VIII. Authorized Official

Name: STEPHEN J KOCHERHANS
Title or Position: OWNER
Credential:
Phone: 505-299-4496