Healthcare Provider Details

I. General information

NPI: 1336583244
Provider Name (Legal Business Name): MIKIKO YAMADA TAKEDA PHARMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/22/2013
Last Update Date: 10/28/2024
Certification Date: 10/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2502 MARBLE AVE NE MSC09 5360
ALBUQUERQUE NM
87131-0001
US

IV. Provider business mailing address

800 BRADBURY DR SE STE 116
ALBUQUERQUE NM
87106-4310
US

V. Phone/Fax

Practice location:
  • Phone: 505-272-6126
  • Fax:
Mailing address:
  • Phone: 505-272-1476
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835P0018X
TaxonomyPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
License NumberRP00007912
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: