Provider Demographics
NPI:1205427978
Name:BUSTAMANTE, ANDREA VICTORIA (RPH)
Entity type:Individual
Prefix:
First Name:ANDREA
Middle Name:VICTORIA
Last Name:BUSTAMANTE
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3224 RHODE ISLAND DR NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87110-2429
Mailing Address - Country:US
Mailing Address - Phone:505-400-5851
Mailing Address - Fax:
Practice Address - Street 1:1421 N RENAISSANCE BLVD NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87107-7018
Practice Address - Country:US
Practice Address - Phone:505-344-0051
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-26
Last Update Date:2021-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMRP000093741835P1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P1300XPharmacy Service ProvidersPharmacistPsychiatric