Provider Demographics
NPI:1114271574
Name:NELLOS, JUANITA M (RPH)
Entity Type:Individual
Prefix:
First Name:JUANITA
Middle Name:M
Last Name:NELLOS
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 1:12201 ACADEMY RD NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87111-8051
Mailing Address - Country:US
Mailing Address - Phone:505-275-9733
Mailing Address - Fax:
Practice Address - Street 1:12201 ACADEMY RD NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87111-8051
Practice Address - Country:US
Practice Address - Phone:505-275-9733
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-06
Last Update Date:2012-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMRP00003593183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM440629OtherNABP