Healthcare Provider Details

I. General information

NPI: 1437170404
Provider Name (Legal Business Name): MJRX V, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/22/2006
Last Update Date: 11/19/2021
Certification Date: 11/19/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2402 W PIERCE ST STE 2B
CARLSBAD NM
88220-3537
US

IV. Provider business mailing address

7209 JEFFERSON ST NE
ALBUQUERQUE NM
87109-4307
US

V. Phone/Fax

Practice location:
  • Phone: 575-885-2979
  • Fax: 575-885-2979
Mailing address:
  • Phone: 505-881-4601
  • Fax: 505-881-4647

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License NumberPH00002988
License Number StateNM

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier55533
Identifier TypeMEDICAID
Identifier StateNM
Identifier Issuer

VIII. Authorized Official

Name: STEPHEN J KOCHERHANS
Title or Position: OWNER/CEO
Credential:
Phone: 505-881-4601