Healthcare Provider Details

I. General information

NPI: 1114496973
Provider Name (Legal Business Name): BRADEN JACOB WALLACE PHARMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/21/2018
Last Update Date: 11/21/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1700 CERRILLOS RD
SANTA FE NM
87505-3026
US

IV. Provider business mailing address

3600 CERRILLOS RD STE 732
SANTA FE NM
87507-2689
US

V. Phone/Fax

Practice location:
  • Phone: 505-946-9387
  • Fax:
Mailing address:
  • Phone: 918-989-6276
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number0022441
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: