Provider Demographics
NPI:1568473114
Name:NOWELL PHARMACY LLC
Entity Type:Organization
Organization Name:NOWELL PHARMACY LLC
Other - Org Name:NOWELL PHARMACY, LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JENNA
Authorized Official - Middle Name:
Authorized Official - Last Name:DOMZALSKI DE RIOS
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMACY
Authorized Official - Phone:575-396-6746
Mailing Address - Street 1:122 W ADAMS AVE
Mailing Address - Street 2:
Mailing Address - City:LOVINGTON
Mailing Address - State:NM
Mailing Address - Zip Code:88260-4010
Mailing Address - Country:US
Mailing Address - Phone:575-396-4242
Mailing Address - Fax:575-396-3133
Practice Address - Street 1:122 W ADAMS AVE
Practice Address - Street 2:
Practice Address - City:LOVINGTON
Practice Address - State:NM
Practice Address - Zip Code:88260-4010
Practice Address - Country:US
Practice Address - Phone:575-396-4242
Practice Address - Fax:575-396-3133
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-10
Last Update Date:2017-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336L0003X
NMPH000012333336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2056596OtherPK
NM56630Medicaid