Provider Demographics
NPI:1033638796
Name:SELF, XONDRIA JENNIFER (PHARMD)
Entity Type:Individual
Prefix:
First Name:XONDRIA
Middle Name:JENNIFER
Last Name:SELF
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2210 JADYN LN
Mailing Address - Street 2:
Mailing Address - City:CLOVIS
Mailing Address - State:NM
Mailing Address - Zip Code:88101-1614
Mailing Address - Country:US
Mailing Address - Phone:575-693-2600
Mailing Address - Fax:
Practice Address - Street 1:700 E 21ST ST
Practice Address - Street 2:
Practice Address - City:CLOVIS
Practice Address - State:NM
Practice Address - Zip Code:88101-3703
Practice Address - Country:US
Practice Address - Phone:575-762-3851
Practice Address - Fax:575-762-5698
Is Sole Proprietor?:No
Enumeration Date:2017-09-13
Last Update Date:2017-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMRP00008794183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist