Provider Demographics
NPI:1770667438
Name:LOVELACE HEALTH SYSTEMS INC
Entity Type:Organization
Organization Name:LOVELACE HEALTH SYSTEMS INC
Other - Org Name:LOVELACE RIO BRAVO 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:505-262-7861
Mailing Address - Fax:505-262-7592
Practice Address - Street 1:200 RIO BRAVO BLVD SE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87105-5904
Practice Address - Country:US
Practice Address - Phone:505-727-5935
Practice Address - Fax:505-727-9067
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
333600000X
NMPH000016883336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2057696OtherPK
NM64121Medicaid
0489130004Medicare NSC