Provider Demographics
NPI:1003997404
Name:RAITT, STEFANIE LEIGH (PHARMD, PHC)
Entity Type:Individual
Prefix:
First Name:STEFANIE
Middle Name:LEIGH
Last Name:RAITT
Suffix:
Gender:F
Credentials:PHARMD, PHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1100 CENTRAL AVE SE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87106-4930
Mailing Address - Country:US
Mailing Address - Phone:505-681-4154
Mailing Address - Fax:505-724-6024
Practice Address - Street 1:1100 CENTRAL AVE SE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87106-4930
Practice Address - Country:US
Practice Address - Phone:505-681-4154
Practice Address - Fax:505-724-6024
Is Sole Proprietor?:No
Enumeration Date:2006-10-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM55831835P1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P1200XPharmacy Service ProvidersPharmacistPharmacotherapy