Healthcare Provider Details

I. General information

NPI: 1831059724
Provider Name (Legal Business Name): KELLY PHAM PHARMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/13/2025
Last Update Date: 11/13/2025
Certification Date: 11/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700 E 21ST ST
CLOVIS NM
88101-3703
US

IV. Provider business mailing address

700 E 21ST ST
CLOVIS NM
88101-3703
US

V. Phone/Fax

Practice location:
  • Phone: 575-762-3851
  • Fax: 575-762-5698
Mailing address:
  • Phone: 575-762-3851
  • Fax: 575-762-5698

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberRP00010398
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: