Healthcare Provider Details

I. General information

NPI: 1912679135
Provider Name (Legal Business Name): HENGAMEH HEIDARIAN- RAISSY PHARMD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/05/2021
Last Update Date: 10/05/2021
Certification Date: 09/21/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

WALGREENS 5001 MONTGOMERY BLVD NE
ALBUQUERQUE NM
87109
US

IV. Provider business mailing address

8100 WYOMING BLVD NE STE M4-127
ALBUQUERQUE NM
87113-1946
US

V. Phone/Fax

Practice location:
  • Phone: 505-250-6761
  • Fax:
Mailing address:
  • Phone: 505-934-5767
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number6213
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: