Healthcare Provider Details

I. General information

NPI: 1447434618
Provider Name (Legal Business Name): LORI ALISON AUTREY RPH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/24/2007
Last Update Date: 12/24/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 WEST BROADWAY
MOUNTAINAIR NM
87036
US

IV. Provider business mailing address

PO BOX 969 111 W, BROADWAY
MOUNTAINAIR NM
87036-0969
US

V. Phone/Fax

Practice location:
  • Phone: 505-847-0242
  • Fax: 505-847-0252
Mailing address:
  • Phone: 505-847-0242
  • Fax: 505-847-0252

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberRPH00006163
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: