Healthcare Provider Details

I. General information

NPI: 1891379616
Provider Name (Legal Business Name): MARIE DISHO ANDRADA PHARM D
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/07/2021
Last Update Date: 05/07/2021
Certification Date: 05/07/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2266 WYOMING BLVD NE
ALBUQUERQUE NM
87112-2620
US

IV. Provider business mailing address

13705 POINSETTIA CT SE
ALBUQUERQUE NM
87123-3955
US

V. Phone/Fax

Practice location:
  • Phone: 505-323-4131
  • Fax:
Mailing address:
  • Phone: 916-367-8835
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberRP00009357
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: