Provider Demographics
NPI:1124127501
Name:DUTRA, JEAN L (RPH)
Entity type:Individual
Prefix:MS
First Name:JEAN
Middle Name:L
Last Name:DUTRA
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:MS
Other - First Name:JEAN
Other - Middle Name:D
Other - Last Name:HICKEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RPH
Mailing Address - Street 1:3727 DRIFTWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:ALAMOGORDO
Mailing Address - State:NM
Mailing Address - Zip Code:88310-3727
Mailing Address - Country:US
Mailing Address - Phone:505-437-6162
Mailing Address - Fax:
Practice Address - Street 1:318 ABALONE LOOP
Practice Address - Street 2:MESCALERO LUDIAN HOSPITAL
Practice Address - City:MESCALERO
Practice Address - State:NM
Practice Address - Zip Code:88340-0210
Practice Address - Country:US
Practice Address - Phone:505-464-4441
Practice Address - Fax:505-464-4422
Is Sole Proprietor?:No
Enumeration Date:2006-09-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO029534183500000X
NM4480183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist