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General NPI Number Information
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NPI Number | 1912059304
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Entity Type | Individual
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Provider Name | ALFRED VICTOR BACA REGISTERED PHARMACIS
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Gender | Male
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Dates
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Enumeration Date | 01/17/2007
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 1719 S AVENUE D
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City | PORTALES
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State | NM
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Zip | 88130-7241
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Country | US
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Telephone | 505-356-8555
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Fax | 505-356-5659
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Provider Business Mailing Address
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Address Line | 1663 S ROOSEVELT ROAD 4
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City | PORTALES
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State | NM
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Zip | 88130-9678
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Country | US
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Telephone | 505-356-8555
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 183500000X
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Taxonomy Name | Pharmacist
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License Number | 4514
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License Number State | NM
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