Healthcare Provider Details

I. General information

NPI: 1013309863
Provider Name (Legal Business Name): LAS CRUCES APOTHECARY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/02/2015
Last Update Date: 03/02/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

525 E MADRID AVE STE 8
LAS CRUCES NM
88001-1671
US

IV. Provider business mailing address

525 E MADRID AVE STE 8
LAS CRUCES NM
88001-1671
US

V. Phone/Fax

Practice location:
  • Phone: 575-541-5030
  • Fax:
Mailing address:
  • Phone: 575-541-5030
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberPH000006912
License Number StateNM

VIII. Authorized Official

Name: DR. KENNETH EDWARD COOPER JR.
Title or Position: PHARMACIST IN CHARGE/OWNER
Credential: PHARM.D.
Phone: 575-541-5030