Healthcare Provider Details

I. General information

NPI: 1154345395
Provider Name (Legal Business Name): BRUCE ROBERT SMITH RPH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/27/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 E ROOSEVELT AVE
GRANTS NM
87020-2118
US

IV. Provider business mailing address

2133 PASEO DEL PRADO NW
ALBUQUERQUE NM
87104-2571
US

V. Phone/Fax

Practice location:
  • Phone: 505-287-3913
  • Fax:
Mailing address:
  • Phone: 505-350-6368
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number3757
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: