Healthcare Provider Details

I. General information

NPI: 1790384261
Provider Name (Legal Business Name): MT. CRISTO PHARMACY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/25/2020
Last Update Date: 06/22/2021
Certification Date: 06/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1155 MCNUTT RD STE 110
SUNLAND PARK NM
88063-9175
US

IV. Provider business mailing address

1155 MCNUTT RD SUITE110
SUNLAND PARK NM
88063-8148
US

V. Phone/Fax

Practice location:
  • Phone: 575-332-9393
  • Fax: 575-332-9391
Mailing address:
  • Phone: 575-332-9393
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: MEHRDAD POURJAVAHERI
Title or Position: MANAGER
Credential: PHARMD
Phone: 575-332-9393