Provider Demographics
NPI:1104094234
Name:WOOLF, NATHAN BLAIR (PHARMACY INTERN)
Entity type:Individual
Prefix:
First Name:NATHAN
Middle Name:BLAIR
Last Name:WOOLF
Suffix:
Gender:F
Credentials:PHARMACY INTERN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 TRAMWAY BLVD SE
Mailing Address - Street 2:SMITH'S PHARMACY
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87123-3934
Mailing Address - Country:US
Mailing Address - Phone:505-296-9751
Mailing Address - Fax:505-271-9095
Practice Address - Street 1:200 TRAMWAY BLVD SE
Practice Address - Street 2:SMITH'S PHARMACY
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87123-3934
Practice Address - Country:US
Practice Address - Phone:505-296-9751
Practice Address - Fax:505-271-9095
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-11
Last Update Date:2008-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMIN00002853183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMIN00002853OtherINTERN LICENSE