Provider Demographics
NPI:1275990640
Name:DOROTHEO, JUSTIN RUSSELL (PHARMD)
Entity Type:Individual
Prefix:MR
First Name:JUSTIN
Middle Name:RUSSELL
Last Name:DOROTHEO
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3167 N KYLE LOOP
Mailing Address - Street 2:
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86004-1837
Mailing Address - Country:US
Mailing Address - Phone:561-715-4749
Mailing Address - Fax:
Practice Address - Street 1:WINSLOW INDIAN HEALTHCARE CENTER (PHARMACY DEPT.)
Practice Address - Street 2:500 INDIANA AVE
Practice Address - City:WINSLOW
Practice Address - State:AZ
Practice Address - Zip Code:86047-7403
Practice Address - Country:US
Practice Address - Phone:928-289-6215
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-01-15
Last Update Date:2018-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS55417183500000X
FLPSI29655183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist