Provider Demographics
NPI:1124382007
Name:DOMZALSKI DE RIOS, JENNA (PHARMD)
Entity Type:Individual
Prefix:MRS
First Name:JENNA
Middle Name:
Last Name:DOMZALSKI DE RIOS
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 1:1828 STANFORD DR NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87106-2538
Mailing Address - Country:US
Mailing Address - Phone:505-803-1411
Mailing Address - Fax:
Practice Address - Street 1:2105 CENTRAL AVE NW
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87104-1605
Practice Address - Country:US
Practice Address - Phone:505-242-2713
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-26
Last Update Date:2012-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMRP00007816183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist