Healthcare Provider Details

I. General information

NPI: 1114114485
Provider Name (Legal Business Name): JEAN ANN GRAHAM RPH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/01/2007
Last Update Date: 10/01/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 WALTER ST NE SUITE 201
ALBUQUERQUE NM
87102-2534
US

IV. Provider business mailing address

500 WALTER ST NE SUITE 201
ALBUQUERQUE NM
87102-2534
US

V. Phone/Fax

Practice location:
  • Phone: 505-727-2900
  • Fax: 505-727-2990
Mailing address:
  • Phone: 505-727-2900
  • Fax: 505-727-2990

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberRP00006835
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: