Healthcare Provider Details

I. General information

NPI: 1124382007
Provider Name (Legal Business Name): JENNA DOMZALSKI DE RIOS PHARMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/26/2012
Last Update Date: 06/26/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2105 CENTRAL AVE NW
ALBUQUERQUE NM
87104-1605
US

IV. Provider business mailing address

1828 STANFORD DR NE
ALBUQUERQUE NM
87106-2538
US

V. Phone/Fax

Practice location:
  • Phone: 505-242-2713
  • Fax:
Mailing address:
  • Phone: 505-803-1411
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberRP00007816
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: