Healthcare Provider Details

I. General information

NPI: 1801933882
Provider Name (Legal Business Name): KATHLEEN T WADE RPH, PHARM D, PHC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/31/2007
Last Update Date: 04/11/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8300 CONSTITUTION PL NE RM 1132
ALBUQUERQUE NM
87110-7637
US

IV. Provider business mailing address

PO BOX 206
CEDAR CREST NM
87008-0206
US

V. Phone/Fax

Practice location:
  • Phone: 505-291-2402
  • Fax: 505-291-2546
Mailing address:
  • Phone: 505-281-5720
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberRP00004892
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code1835P0018X
TaxonomyPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
License Number4892
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: