Healthcare Provider Details

I. General information

NPI: 1972402246
Provider Name (Legal Business Name): RUDI PAVEL DADJEU WOPEMWO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/03/2026
Last Update Date: 11/03/2026
Certification Date: 11/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

224 W D.L. INGRAM AVE
CLOVIS NM
88103
US

IV. Provider business mailing address

108 CHISUM DR
CLOVIS NM
88101-9193
US

V. Phone/Fax

Practice location:
  • Phone: 575-784-4053
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number21503
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: