Healthcare Provider Details

I. General information

NPI: 1033271044
Provider Name (Legal Business Name): SCARLET DANIELLE SOUTHERN RPH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/15/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

INTERSTATE 40, EXIT 102
SAN FIDEL NM
87049
US

IV. Provider business mailing address

924 AVENIDA MANANA NE
ALBUQUERQUE NM
87110-6167
US

V. Phone/Fax

Practice location:
  • Phone: 505-552-5394
  • Fax: 505-552-5464
Mailing address:
  • Phone: 505-681-9780
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835P1200X
TaxonomyPharmacotherapy Pharmacist
License Number11833
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: