Provider Demographics
NPI:1043197080
Name:EDEN PHARMACY, LLC
Entity type:Organization
Organization Name:EDEN PHARMACY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST IN CHARGE, PHARMD
Authorized Official - Prefix:
Authorized Official - First Name:ANGELA
Authorized Official - Middle Name:
Authorized Official - Last Name:NICKENS
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:505-677-8842
Mailing Address - Street 1:8300 CARMEL AVE NE STE 601
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87122-3125
Mailing Address - Country:US
Mailing Address - Phone:505-677-8842
Mailing Address - Fax:505-717-1539
Practice Address - Street 1:8300 CARMEL AVE NE STE 601
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87122-3125
Practice Address - Country:US
Practice Address - Phone:505-677-8842
Practice Address - Fax:505-717-1539
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-08-20
Last Update Date:2025-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0004XSuppliersPharmacyCompounding Pharmacy