Healthcare Provider Details

I. General information

NPI: 1730430059
Provider Name (Legal Business Name): KELLI DALE AVANT RPH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/26/2012
Last Update Date: 09/26/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2220 N GRIMES ST
HOBBS NM
88240-2716
US

IV. Provider business mailing address

2220 N GRIMES ST
HOBBS NM
88240-2716
US

V. Phone/Fax

Practice location:
  • Phone: 575-393-1576
  • Fax:
Mailing address:
  • Phone: 575-393-1576
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number00007763
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: