Healthcare Provider Details

I. General information

NPI: 1568689560
Provider Name (Legal Business Name): KATHLEEN ALEXANDRA WEST RPH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/19/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 WEST BROADWAY
MOUNTAINAIR NM
87036-0969
US

IV. Provider business mailing address

205 RAVEN RD
TIJERAS NM
87059-8016
US

V. Phone/Fax

Practice location:
  • Phone: 505-847-0242
  • Fax: 505-847-0252
Mailing address:
  • Phone: 505-281-1195
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number5912
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: