Provider Demographics
NPI:1417575598
Name:FERNANDES, DESMOND (PHARMD)
Entity Type:Individual
Prefix:
First Name:DESMOND
Middle Name:
Last Name:FERNANDES
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 1:2101 S TYLER ST
Mailing Address - Street 2:
Mailing Address - City:AMARILLO
Mailing Address - State:TX
Mailing Address - Zip Code:79109-2632
Mailing Address - Country:US
Mailing Address - Phone:806-570-2638
Mailing Address - Fax:
Practice Address - Street 1:1835 N MAIN ST
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:NM
Practice Address - Zip Code:88201-5168
Practice Address - Country:US
Practice Address - Phone:575-624-0423
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-06
Last Update Date:2020-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMRP00009283183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist