Provider Demographics
NPI:1992154579
Name:BESTCARE PHARMACY 4 LLC
Entity type:Organization
Organization Name:BESTCARE PHARMACY 4 LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RANJITHA
Authorized Official - Middle Name:
Authorized Official - Last Name:PALLAPOTHU
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:917-769-8014
Mailing Address - Street 1:5400 GIBSON BLVD SE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87108-4729
Mailing Address - Country:US
Mailing Address - Phone:505-268-2030
Mailing Address - Fax:505-268-2022
Practice Address - Street 1:2349 STATE ROAD 522
Practice Address - Street 2:
Practice Address - City:QUESTA
Practice Address - State:NM
Practice Address - Zip Code:87556
Practice Address - Country:US
Practice Address - Phone:505-268-2033
Practice Address - Fax:505-214-5144
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-06-06
Last Update Date:2017-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMPH00004237333600000X
3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2160349OtherPK