=====================================================
General NPI Number Information
=====================================================
NPI Number | 1003997404
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | STEFANIE LEIGH RAITT PHARMD, PHC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/18/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1100 CENTRAL AVE SE
-----------------------------------------------------
City | ALBUQUERQUE
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87106-4930
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 505-681-4154
-----------------------------------------------------
Fax | 505-724-6024
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1100 CENTRAL AVE SE
-----------------------------------------------------
City | ALBUQUERQUE
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87106-4930
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 505-681-4154
-----------------------------------------------------
Fax | 505-724-6024
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1835P1200X
-----------------------------------------------------
Taxonomy Name | Pharmacotherapy Pharmacist
-----------------------------------------------------
License Number | 5583
-----------------------------------------------------
License Number State | NM
-----------------------------------------------------