Provider Demographics
NPI:1982753232
Name:ALBUQUERQUE MANOR PHARMACY, INC
Entity Type:Organization
Organization Name:ALBUQUERQUE MANOR PHARMACY, INC
Other - Org Name:ALBUQUERQUE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VP OF PHARMACY OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:ANGELA
Authorized Official - Middle Name:
Authorized Official - Last Name:PERSYN
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:210-510-2692
Mailing Address - Street 1:6601 BLANCO RD
Mailing Address - Street 2:SUITE 201
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78216-6102
Mailing Address - Country:US
Mailing Address - Phone:210-510-2692
Mailing Address - Fax:210-736-4438
Practice Address - Street 1:500 LOUISIANA BLVD NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87108-2051
Practice Address - Country:US
Practice Address - Phone:505-262-5728
Practice Address - Fax:505-262-5779
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-09
Last Update Date:2024-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
NMPH000014383336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2058119OtherPK
NM65698Medicaid