Provider Demographics
NPI:1417150020
Name:GHAFFARI MEDICAL PHARMACY
Entity type:Organization
Organization Name:GHAFFARI MEDICAL PHARMACY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MISS
Authorized Official - First Name:LINDA
Authorized Official - Middle Name:R
Authorized Official - Last Name:GHAFFARI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:505-749-2915
Mailing Address - Street 1:121 W 5TH ST
Mailing Address - Street 2:
Mailing Address - City:CLOVIS
Mailing Address - State:NM
Mailing Address - Zip Code:88101-7301
Mailing Address - Country:US
Mailing Address - Phone:505-762-3294
Mailing Address - Fax:505-763-0062
Practice Address - Street 1:2929 N COORS NW 3RD FLOOR, STE 310H
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87120
Practice Address - Country:US
Practice Address - Phone:505-836-4801
Practice Address - Fax:505-836-4801
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-09
Last Update Date:2007-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM63593729251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM63593729Medicaid