Provider Demographics
NPI:1730383548
Name:PHARMACY CAPITAL LLC
Entity type:Organization
Organization Name:PHARMACY CAPITAL LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF PHARMACY
Authorized Official - Prefix:
Authorized Official - First Name:TERI
Authorized Official - Middle Name:
Authorized Official - Last Name:ROLAN
Authorized Official - Suffix:
Authorized Official - Credentials:PHARM D
Authorized Official - Phone:505-243-2011
Mailing Address - Street 1:717 ENCINO PL NE
Mailing Address - Street 2:STE 1
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87102-2611
Mailing Address - Country:US
Mailing Address - Phone:505-243-2010
Mailing Address - Fax:505-242-3216
Practice Address - Street 1:717 ENCINO PL NE
Practice Address - Street 2:STE 1
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87102-2611
Practice Address - Country:US
Practice Address - Phone:505-243-2010
Practice Address - Fax:505-242-3216
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-14
Last Update Date:2016-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMPH4108OtherPHARMACY LICENSE
NM000T2383Medicaid