Healthcare Provider Details

I. General information

NPI: 1720140569
Provider Name (Legal Business Name): WELLBORN PHARMACY, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/15/2006
Last Update Date: 07/20/2022
Certification Date: 07/20/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1923 S 1ST ST
TUCUMCARI NM
88401-3826
US

IV. Provider business mailing address

PO BOX 985
TUCUMCARI NM
88401-0985
US

V. Phone/Fax

Practice location:
  • Phone: 575-461-2784
  • Fax: 575-461-2994
Mailing address:
  • Phone: 575-461-2784
  • Fax: 575-461-2994

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 NumberPH00003107
License Number StateNM

VIII. Authorized Official

Name: BRIAN WILSON
Title or Position: OWNER / PRESIDENT
Credential:
Phone: 575-461-2784