Provider Demographics
NPI:1679891238
Name:PORTALES PROFESSIONAL COMPOUNDING LLC
Entity Type:Organization
Organization Name:PORTALES PROFESSIONAL COMPOUNDING LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST
Authorized Official - Prefix:MR
Authorized Official - First Name:ALFRED
Authorized Official - Middle Name:VICTOR
Authorized Official - Last Name:BACA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:575-356-6068
Mailing Address - Street 1:1719 S. AVE D
Mailing Address - Street 2:
Mailing Address - City:PORTALES
Mailing Address - State:NM
Mailing Address - Zip Code:88130
Mailing Address - Country:US
Mailing Address - Phone:575-356-8433
Mailing Address - Fax:
Practice Address - Street 1:1719 S. AVE D
Practice Address - Street 2:
Practice Address - City:PORTALES
Practice Address - State:NM
Practice Address - Zip Code:88130
Practice Address - Country:US
Practice Address - Phone:575-356-8433
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-05-06
Last Update Date:2010-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMPH000024913336C0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0004XSuppliersPharmacyCompounding Pharmacy