Healthcare Provider Details

I. General information

NPI: 1750197489
Provider Name (Legal Business Name): MAYA HAYNES
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/07/2024
Last Update Date: 12/07/2024
Certification Date: 12/07/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1101 WILMOORE DR SE
ALBUQUERQUE NM
87106-4116
US

IV. Provider business mailing address

1101 WILMOORE DR SE
ALBUQUERQUE NM
87106-4116
US

V. Phone/Fax

Practice location:
  • Phone: 575-318-3179
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberRP0001022
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: