Provider Demographics
NPI:1902214109
Name:BACA, RYAN (PHARM D)
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:
Last Name:BACA
Suffix:
Gender:M
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7220 CENTRAL AVE SE APT 1071
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87108-2074
Mailing Address - Country:US
Mailing Address - Phone:505-603-8172
Mailing Address - Fax:
Practice Address - Street 1:5201 CENTRAL AVE NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87108-1328
Practice Address - Country:US
Practice Address - Phone:505-217-9907
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-07-31
Last Update Date:2014-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMRP00008202183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist