Healthcare Provider Details

I. General information

NPI: 1013317189
Provider Name (Legal Business Name): MICHELLE RENEE WITTENMYER PHARMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/26/2014
Last Update Date: 10/23/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

315 N MAIN ST
BELEN NM
87002-3715
US

IV. Provider business mailing address

6605 4TH ST NW
LOS RANCHOS DE ALBUQUERQUE NM
87107
US

V. Phone/Fax

Practice location:
  • Phone: 505-861-1762
  • Fax: 505-864-6998
Mailing address:
  • Phone: 505-345-9059
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberRP00008240
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: