Provider Demographics
NPI:1205103058
Name:BHAKTA, AJAY
Entity type:Individual
Prefix:
First Name:AJAY
Middle Name:
Last Name:BHAKTA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1655 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88005-3117
Mailing Address - Country:US
Mailing Address - Phone:505-699-9060
Mailing Address - Fax:
Practice Address - Street 1:1655 S MAIN ST
Practice Address - Street 2:
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88005-3117
Practice Address - Country:US
Practice Address - Phone:505-699-9060
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-22
Last Update Date:2011-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMRP00007759183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist