Healthcare Provider Details

I. General information

NPI: 1336592096
Provider Name (Legal Business Name): ANDREA MARSHALL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/18/2016
Last Update Date: 07/18/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3728 N PRINCE ST
CLOVIS NM
88101-9744
US

IV. Provider business mailing address

3728 N PRINCE ST
CLOVIS NM
88101-9744
US

V. Phone/Fax

Practice location:
  • Phone: 575-769-2389
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberRP00007636
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number051291212
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberRPH.03329307-3
License Number StateOH
# 4
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberPS54787
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: