Healthcare Provider Details

I. General information

NPI: 1164261558
Provider Name (Legal Business Name): JOSE BAUTISTA III PHARMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/23/2024
Last Update Date: 05/23/2024
Certification Date: 05/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2450 S TELSHOR BLVD
LAS CRUCES NM
88011-5076
US

IV. Provider business mailing address

11549 MACAW PALM DR
EL PASO TX
79936-1486
US

V. Phone/Fax

Practice location:
  • Phone: 575-522-8641
  • Fax:
Mailing address:
  • Phone: 915-538-8452
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberIN00004887
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: