Provider Demographics
NPI:1114114485
Name:GRAHAM, JEAN ANN (RPH)
Entity Type:Individual
Prefix:
First Name:JEAN
Middle Name:ANN
Last Name:GRAHAM
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 WALTER ST NE
Mailing Address - Street 2:SUITE 201
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87102-2534
Mailing Address - Country:US
Mailing Address - Phone:505-727-2900
Mailing Address - Fax:505-727-2990
Practice Address - Street 1:500 WALTER ST NE
Practice Address - Street 2:SUITE 201
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87102-2534
Practice Address - Country:US
Practice Address - Phone:505-727-2900
Practice Address - Fax:505-727-2990
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-01
Last Update Date:2007-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMRP00006835183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist