Provider Demographics
NPI:1205409158
Name:LANDAVERDE, ALEXANDRIA MONIQUE (PHARM D)
Entity Type:Individual
Prefix:
First Name:ALEXANDRIA
Middle Name:MONIQUE
Last Name:LANDAVERDE
Suffix:
Gender:F
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:781 S THORNWOOD WAY
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-3530
Mailing Address - Country:US
Mailing Address - Phone:541-212-9027
Mailing Address - Fax:
Practice Address - Street 1:1620 N WHITLEY DR
Practice Address - Street 2:
Practice Address - City:FRUITLAND
Practice Address - State:ID
Practice Address - Zip Code:83619-2129
Practice Address - Country:US
Practice Address - Phone:208-452-7075
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-19
Last Update Date:2021-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDP9427183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist