=====================================================
General NPI Number Information
=====================================================
NPI Number | 1548326960
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GHAFFARI MEDICAL PHARMACY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/29/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 813 N RICHARDSON AVE STE B
-----------------------------------------------------
City | ROSWELL
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 88201-4968
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 505-623-8404
-----------------------------------------------------
Fax | 505-763-0062
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 121 W 5TH ST
-----------------------------------------------------
City | CLOVIS
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 88101-7301
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 505-623-8404
-----------------------------------------------------
Fax | 505-763-0062
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | LINDA R GHAFFARI
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 505-749-2915
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251E00000X
-----------------------------------------------------
Taxonomy Name | Home Health Agency
-----------------------------------------------------
License Number | 00350818
-----------------------------------------------------
License Number State | NM
-----------------------------------------------------