Provider Demographics
NPI:1215942826
Name:LAMC WHITE ROCK PHARMACY
Entity type:Organization
Organization Name:LAMC WHITE ROCK PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACY DIR
Authorized Official - Prefix:
Authorized Official - First Name:ANABEL
Authorized Official - Middle Name:
Authorized Official - Last Name:CANDELARIA
Authorized Official - Suffix:
Authorized Official - Credentials:PHARM D
Authorized Official - Phone:505-661-9568
Mailing Address - Street 1:WHITE ROCK MED CLINIC STE B
Mailing Address - Street 2:
Mailing Address - City:WHITE ROCK
Mailing Address - State:NM
Mailing Address - Zip Code:87544
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:WHITE ROCK MED CLINIC STE B
Practice Address - Street 2:
Practice Address - City:WHITE ROCK
Practice Address - State:NM
Practice Address - Zip Code:87544
Practice Address - Country:US
Practice Address - Phone:505-672-3701
Practice Address - Fax:505-672-0369
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-30
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMPH00002442333600000X
3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered333600000XSuppliersPharmacy
Not Answered3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM65086Medicaid
3203940OtherOTHER ID NUMBER-COMMERCIAL NUMBER
NM65086Medicaid