Healthcare Provider Details

I. General information

NPI: 1265887996
Provider Name (Legal Business Name): TW WELLNESS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/02/2016
Last Update Date: 05/02/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8225 4TH ST NW
LOS RANCHOS NM
87114-1014
US

IV. Provider business mailing address

8225 4TH ST NW
LOS RANCHOS NM
87114-1014
US

V. Phone/Fax

Practice location:
  • Phone: 505-717-2342
  • Fax: 505-492-2549
Mailing address:
  • Phone: 505-717-2342
  • Fax: 505-492-2549

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License NumberCS00222956
License Number StateNM

VIII. Authorized Official

Name: BENJAMIN WHITE
Title or Position: OWNER
Credential:
Phone: 505-717-2342