Provider Demographics
NPI:1316021066
Name:LOVELACE HEALTH SYSTEMS INC
Entity Type:Organization
Organization Name:LOVELACE HEALTH SYSTEMS INC
Other - Org Name:LOVELACE OUTPATIENT PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:BRAD
Authorized Official - Middle Name:
Authorized Official - Last Name:TROM
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:505-727-1299
Mailing Address - Street 1:PO BOX 27803
Mailing Address - Street 2:ATTN PHARMACY FINANCE
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87125-7803
Mailing Address - Country:US
Mailing Address - Phone:505-727-1281
Mailing Address - Fax:505-727-1245
Practice Address - Street 1:5400 GIBSON BLVD SE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87108-4729
Practice Address - Country:US
Practice Address - Phone:505-727-5915
Practice Address - Fax:505-727-1241
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LOVELACE HEALTH SYSTEM
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-10-25
Last Update Date:2014-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMPH000016853336C0003X
3336C0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2057064OtherPK
NM64113Medicaid
NM64113Medicaid