Provider Demographics
NPI:1154651610
Name:TANNER, CAITLYN (PHD)
Entity Type:Individual
Prefix:
First Name:CAITLYN
Middle Name:
Last Name:TANNER
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5400 GIBSON BLVD SE
Mailing Address - Street 2:2ND FLOOR / PHARMACY
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87108-4729
Mailing Address - Country:US
Mailing Address - Phone:505-262-7000
Mailing Address - Fax:
Practice Address - Street 1:500 WALTER ST NE
Practice Address - Street 2:SUITE 301
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87102-2534
Practice Address - Country:US
Practice Address - Phone:505-262-7451
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-01-06
Last Update Date:2010-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMRP00007026183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist