Healthcare Provider Details

I. General information

NPI: 1285924803
Provider Name (Legal Business Name): COMPLETE CARE PHARMACY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/15/2011
Last Update Date: 01/13/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4940 CORRALES RD SUITE 200
CORRALES NM
87048-8673
US

IV. Provider business mailing address

4940 CORRALES RD SUITE 200
CORRALES NM
87048-8673
US

V. Phone/Fax

Practice location:
  • Phone: 505-897-3784
  • Fax: 505-897-3795
Mailing address:
  • Phone: 505-897-3784
  • Fax: 505-897-3795

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License NumberPH00004048
License Number StateNM

VIII. Authorized Official

Name: MIKE GALLEGOS
Title or Position: OWNER,PIC,AO
Credential: PHARMD,RPH
Phone: 505-897-3784