Provider Demographics
NPI:1740559913
Name:AOM PHARMACY ADVANCED ORTHOMOLECULAR MEDICINE
Entity Type:Organization
Organization Name:AOM PHARMACY ADVANCED ORTHOMOLECULAR MEDICINE
Other - Org Name:AOM PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/PHARMACIST IN CHARGE
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:
Authorized Official - Last Name:MARCILLA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:505-280-5078
Mailing Address - Street 1:4514 CENTRAL AVE SE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87108-1212
Mailing Address - Country:US
Mailing Address - Phone:505-266-2022
Mailing Address - Fax:505-266-2882
Practice Address - Street 1:4514 CENTRAL AVE SE
Practice Address - Street 2:SE
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87108-1212
Practice Address - Country:US
Practice Address - Phone:505-266-2022
Practice Address - Fax:505-266-2882
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-18
Last Update Date:2012-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0004X, 3336S0011X
NMPH000033443336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
3212242OtherNCPDP PROVIDER IDENTIFICATION NUMBER