Healthcare Provider Details

I. General information

NPI: 1558795039
Provider Name (Legal Business Name): JESSICA LAUREN STAFFORD PHARMD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/03/2013
Last Update Date: 12/07/2019
Certification Date: 12/07/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

415 N MAIN AVE
AZTEC NM
87410-1927
US

IV. Provider business mailing address

415 N MAIN AVE
AZTEC NM
87410-1927
US

V. Phone/Fax

Practice location:
  • Phone: 216-272-2620
  • Fax:
Mailing address:
  • Phone: 216-272-2620
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberRP448112
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberRP00008347
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: