Healthcare Provider Details

I. General information

NPI: 1508069477
Provider Name (Legal Business Name): STEPHANIE ANN HEADRICK RPH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/07/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1815 CENTRAL AVE NW
ALBUQUERQUE NM
87104-1143
US

IV. Provider business mailing address

5322 IRONWOOD DR NW
ALBUQUERQUE NM
87114-4630
US

V. Phone/Fax

Practice location:
  • Phone: 505-247-4141
  • Fax: 505-843-6249
Mailing address:
  • Phone: 505-898-0232
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number00005433
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: