Healthcare Provider Details

I. General information

NPI: 1598074585
Provider Name (Legal Business Name): EDNA V SANDOVAL RPH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/24/2010
Last Update Date: 09/24/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2709 PAN AM FWY NE STE G
ALBUQUERQUE NM
87107-1650
US

IV. Provider business mailing address

PO BOX 16084
SANTA FE NM
87592-6084
US

V. Phone/Fax

Practice location:
  • Phone: 505-344-4739
  • Fax:
Mailing address:
  • Phone: 505-471-3021
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number4883
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: