Healthcare Provider Details

I. General information

NPI: 1689866519
Provider Name (Legal Business Name): CECILY M BOLTE PHARMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/14/2007
Last Update Date: 08/14/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

440 SAINT MICHAELS DR
SANTA FE NM
87505-7637
US

IV. Provider business mailing address

440 SAINT MICHAELS DR
SANTA FE NM
87505-7637
US

V. Phone/Fax

Practice location:
  • Phone: 505-995-2947
  • Fax: 505-995-2410
Mailing address:
  • Phone: 505-995-2947
  • Fax: 505-995-2410

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberRP00006892
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: