Healthcare Provider Details

I. General information

NPI: 1588654867
Provider Name (Legal Business Name): ROXANN ISRAELLE DOMINGUEZ PHARMD
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 10/26/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2400 LOUISIANA BLVD NE BUILDING 5, SUITE 600
ALBUQUERQUE NM
87110-4303
US

IV. Provider business mailing address

6601 TENNYSON ST NE #4203
ALBUQUERQUE NM
87111-8161
US

V. Phone/Fax

Practice location:
  • Phone: 505-346-9566
  • Fax:
Mailing address:
  • Phone: 512-736-4638
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835P1300X
TaxonomyPsychiatric Pharmacist
License NumberRP00006828
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: