Provider Demographics
NPI:1912059304
Name:BACA, ALFRED VICTOR (REGISTERED PHARMACIS)
Entity Type:Individual
Prefix:MR
First Name:ALFRED
Middle Name:VICTOR
Last Name:BACA
Suffix:
Gender:M
Credentials:REGISTERED PHARMACIS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1663 S ROOSEVELT ROAD 4
Mailing Address - Street 2:
Mailing Address - City:PORTALES
Mailing Address - State:NM
Mailing Address - Zip Code:88130-9678
Mailing Address - Country:US
Mailing Address - Phone:505-356-8555
Mailing Address - Fax:
Practice Address - Street 1:1719 S AVENUE D
Practice Address - Street 2:
Practice Address - City:PORTALES
Practice Address - State:NM
Practice Address - Zip Code:88130-7241
Practice Address - Country:US
Practice Address - Phone:505-356-8555
Practice Address - Fax:505-356-5659
Is Sole Proprietor?:No
Enumeration Date:2007-01-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM4514183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist