Healthcare Provider Details

I. General information

NPI: 1568862274
Provider Name (Legal Business Name): KRISTINE GODDARD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/29/2014
Last Update Date: 08/29/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

26180 U.S 70
RUIDOSO DOWNS NM
88346
US

IV. Provider business mailing address

7401 SAN PEDRO DR NE TRLR #57
ALBUQUERQUE NM
87109-4611
US

V. Phone/Fax

Practice location:
  • Phone: 575-378-8050
  • Fax:
Mailing address:
  • Phone: 505-307-5023
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberIN00003372
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: