Provider Demographics
NPI:1285924803
Name:COMPLETE CARE PHARMACY LLC
Entity type:Organization
Organization Name:COMPLETE CARE PHARMACY LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER,PIC,AO
Authorized Official - Prefix:
Authorized Official - First Name:MIKE
Authorized Official - Middle Name:
Authorized Official - Last Name:GALLEGOS
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD,RPH
Authorized Official - Phone:505-897-3784
Mailing Address - Street 1:4940 CORRALES RD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:CORRALES
Mailing Address - State:NM
Mailing Address - Zip Code:87048-8673
Mailing Address - Country:US
Mailing Address - Phone:505-897-3784
Mailing Address - Fax:505-897-3795
Practice Address - Street 1:4940 CORRALES RD
Practice Address - Street 2:SUITE 200
Practice Address - City:CORRALES
Practice Address - State:NM
Practice Address - Zip Code:87048-8673
Practice Address - Country:US
Practice Address - Phone:505-897-3784
Practice Address - Fax:505-897-3795
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-15
Last Update Date:2017-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMPH000040483336C0003X, 3336C0003X
3336C0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2142883OtherPK
NM96472031Medicaid