Provider Demographics
NPI:1568862274
Name:GODDARD, KRISTINE
Entity Type:Individual
Prefix:
First Name:KRISTINE
Middle Name:
Last Name:GODDARD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7401 SAN PEDRO DR NE
Mailing Address - Street 2:TRLR #57
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87109-4611
Mailing Address - Country:US
Mailing Address - Phone:505-307-5023
Mailing Address - Fax:
Practice Address - Street 1:26180 U.S 70
Practice Address - Street 2:
Practice Address - City:RUIDOSO DOWNS
Practice Address - State:NM
Practice Address - Zip Code:88346
Practice Address - Country:US
Practice Address - Phone:575-378-8050
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-29
Last Update Date:2014-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMIN00003372183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist