Provider Demographics
NPI:1962646265
Name:LOVELACE HEALTH SYSTEMS INC
Entity Type:Organization
Organization Name:LOVELACE HEALTH SYSTEMS INC
Other - Org Name:LOVELACE SPECIALTY 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:PHARMACY FINANCE
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87125-7803
Mailing Address - Country:US
Mailing Address - Phone:505-727-1273
Mailing Address - Fax:505-727-7439
Practice Address - Street 1:500 WALTER ST NE
Practice Address - Street 2:SUITE 202B
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87102-2534
Practice Address - Country:US
Practice Address - Phone:505-727-1299
Practice Address - Fax:505-727-2990
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LOVELACE HEALTH SYSTEM
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-04-30
Last Update Date:2014-03-19
Deactivation Date:2011-11-09
Deactivation Code:
Reactivation Date:2011-11-22
Provider Licenses
StateLicense IDTaxonomies
NMPH000031673336S0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM371068Medicaid
2120305OtherPK
NM371068Medicaid