Healthcare Provider Details

I. General information

NPI: 1811444151
Provider Name (Legal Business Name): BRIAN GUTIERREZ
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/03/2016
Last Update Date: 09/03/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3011 N MAIN ST
LAS CRUCES NM
88001-1164
US

IV. Provider business mailing address

455 ITHACA CT APT 802
LAS CRUCES NM
88011-7181
US

V. Phone/Fax

Practice location:
  • Phone: 575-647-8878
  • Fax:
Mailing address:
  • Phone: 585-503-4060
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberRP00008063
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: