Provider Demographics
NPI:1245688407
Name:CRLKEMPER
Entity type:Organization
Organization Name:CRLKEMPER
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/AO
Authorized Official - Prefix:
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:
Authorized Official - Last Name:KEMPER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:505-967-5033
Mailing Address - Street 1:312 N CALIFORNIA ST
Mailing Address - Street 2:
Mailing Address - City:SOCORRO
Mailing Address - State:NM
Mailing Address - Zip Code:87801-4207
Mailing Address - Country:US
Mailing Address - Phone:575-835-2125
Mailing Address - Fax:575-835-2026
Practice Address - Street 1:312 N CALIFORNIA ST
Practice Address - Street 2:
Practice Address - City:SOCORRO
Practice Address - State:NM
Practice Address - Zip Code:87801-4207
Practice Address - Country:US
Practice Address - Phone:575-835-2125
Practice Address - Fax:575-835-2026
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-05-28
Last Update Date:2016-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3336C0004X, 333600000X
NMPH000042783336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336C0004XSuppliersPharmacyCompounding PharmacyGroup - Single Specialty
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2160348OtherPK