Healthcare Provider Details

I. General information

NPI: 1982749453
Provider Name (Legal Business Name): GUADALUPE COUNTY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/21/2007
Last Update Date: 09/12/2023
Certification Date: 09/12/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

117 CAMINO DE VIDA STE 200
SANTA ROSA NM
88435-2267
US

IV. Provider business mailing address

117 CAMINO DE VIDA STE 200
SANTA ROSA NM
88435-2267
US

V. Phone/Fax

Practice location:
  • Phone: 575-472-5666
  • Fax: 575-472-9666
Mailing address:
  • Phone: 575-472-5666
  • Fax: 575-472-9666

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License NumberPH00003554
License Number StateNM

VIII. Authorized Official

Name: CHRISTINA CAMPOS
Title or Position: ADMINISTRATOR
Credential: MBA
Phone: 575-472-5666