Provider Demographics
NPI:1427281740
Name:TSOODLE, THERESA ELAINE (DPH)
Entity type:Individual
Prefix:
First Name:THERESA
Middle Name:ELAINE
Last Name:TSOODLE
Suffix:
Gender:F
Credentials:DPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1870 E HIGHWAY 66
Mailing Address - Street 2:
Mailing Address - City:GALLUP
Mailing Address - State:NM
Mailing Address - Zip Code:87301-4955
Mailing Address - Country:US
Mailing Address - Phone:505-722-9499
Mailing Address - Fax:505-722-7988
Practice Address - Street 1:1870 E HIGHWAY 66
Practice Address - Street 2:
Practice Address - City:GALLUP
Practice Address - State:NM
Practice Address - Zip Code:87301-4955
Practice Address - Country:US
Practice Address - Phone:505-722-9499
Practice Address - Fax:505-722-7988
Is Sole Proprietor?:No
Enumeration Date:2009-09-02
Last Update Date:2009-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM7115183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist