Healthcare Provider Details

I. General information

NPI: 1679232284
Provider Name (Legal Business Name): SHARON RAE LUNDIN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/10/2021
Last Update Date: 12/10/2021
Certification Date: 12/10/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

221 WEST HALL STREET UNITED DRUG
HATCH NM
87937
US

IV. Provider business mailing address

P.O. BOX 36
RADIUM SPRINGS NM
88054
US

V. Phone/Fax

Practice location:
  • Phone: 575-267-5127
  • Fax:
Mailing address:
  • Phone: 575-654-3855
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberRP00007438
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: