Healthcare Provider Details

I. General information

NPI: 1407986680
Provider Name (Legal Business Name): EUGENE L GUTIERREZ
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/06/2007
Last Update Date: 04/26/2010
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

1000 E ROOSEVELT AVE
GRANTS NM
87020-2118
US

V. Phone/Fax

Practice location:
  • Phone: 505-287-3913
  • Fax: 505-287-4379
Mailing address:
  • Phone: 505-287-3913
  • Fax: 505-287-4379

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License NumberPH00001734
License Number StateNM

VIII. Authorized Official

Name: MR. BRUCE R. SMITH
Title or Position: RPH PHARMACIST
Credential: RPH
Phone: 505-287-3913