Provider Demographics
NPI:1154345395
Name:SMITH, BRUCE ROBERT (RPH)
Entity type:Individual
Prefix:MR
First Name:BRUCE
Middle Name:ROBERT
Last Name:SMITH
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2133 PASEO DEL PRADO NW
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87104-2571
Mailing Address - Country:US
Mailing Address - Phone:505-350-6368
Mailing Address - Fax:
Practice Address - Street 1:1000 E ROOSEVELT AVE
Practice Address - Street 2:
Practice Address - City:GRANTS
Practice Address - State:NM
Practice Address - Zip Code:87020-2118
Practice Address - Country:US
Practice Address - Phone:505-287-3913
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM3757183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist