Provider Demographics
NPI:1083295562
Name:ADORNETTO, ZACHRY LANE
Entity Type:Individual
Prefix:
First Name:ZACHRY
Middle Name:LANE
Last Name:ADORNETTO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15200 HIGHWAY 152
Mailing Address - Street 2:
Mailing Address - City:MOBEETIE
Mailing Address - State:TX
Mailing Address - Zip Code:79061-4712
Mailing Address - Country:US
Mailing Address - Phone:432-413-3695
Mailing Address - Fax:
Practice Address - Street 1:HWY 191, HOSPITAL ROAD
Practice Address - Street 2:
Practice Address - City:CHINLE
Practice Address - State:AZ
Practice Address - Zip Code:86503
Practice Address - Country:US
Practice Address - Phone:928-674-8114
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-16
Last Update Date:2021-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX67740183500000X
OK19010183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist