Healthcare Provider Details

I. General information

NPI: 1740513506
Provider Name (Legal Business Name): JESSICA RUTH SWEENEY PHARM TECH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/11/2009
Last Update Date: 09/11/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2001 CHAMISA ST
SANTA FE NM
87505-3441
US

IV. Provider business mailing address

2001 CHAMISA ST
SANTA FE NM
87505-3441
US

V. Phone/Fax

Practice location:
  • Phone: 505-982-2129
  • Fax: 505-992-1149
Mailing address:
  • Phone: 505-982-2129
  • Fax: 505-992-1149

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183700000X
TaxonomyPharmacy Technician
License Number290101040760362
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: