MEDICARE: PRIME THERAPEUTICS LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	333600000X	Pharmacy
2	3336M0002X	Mail Order Pharmacy	PH00002880	NM

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2059011	OTHER		PK

General Provider Information

NPI Number	:	1265508360
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PRIME THERAPEUTICS LLC

Provider Business Mailing Address
First Line	:	PO BOX 27836
Second Line	:
City	:	ALBUQUERQUE
State	:	NM
Zip	:	87125-7836
Country	:	US
Telephone Number	:	877-357-7463
Fax Number	:

Provider Business Practice Location Address
First Line	:	4580 PARADISE BLVD NW
Second Line	:
City	:	ALBUQUERQUE
State	:	NM
Zip	:	87114-4105
Country	:	US
Telephone Number	:	877-357-7463
Fax Number	:	888-215-1811

Authorized Official
Title or Position	:	DIRECTOR PROFESSIONAL PRACTICES
Name	:	LUGINA MENDEZ-HARPER
Credential	:	PHARMD
Telephone Number	:	505-206-1089

Provider Enumeration Date	:	11/28/2006
Last Update Date	:	01/18/2017

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Directions to “PRIME THERAPEUTICS LLC ” Practice Location

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