Provider Demographics
NPI:1598356974
Name:MBA, VANESSA ORIE (PHARMD)
Entity Type:Individual
Prefix:
First Name:VANESSA
Middle Name:ORIE
Last Name:MBA
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1202 N RIVERSIDE DR
Mailing Address - Street 2:
Mailing Address - City:ESPANOLA
Mailing Address - State:NM
Mailing Address - Zip Code:87532-2811
Mailing Address - Country:US
Mailing Address - Phone:505-367-3594
Mailing Address - Fax:
Practice Address - Street 1:1202 N RIVERSIDE DR
Practice Address - Street 2:
Practice Address - City:ESPANOLA
Practice Address - State:NM
Practice Address - Zip Code:87532-2811
Practice Address - Country:US
Practice Address - Phone:505-367-3594
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-28
Last Update Date:2021-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMRP00009431183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist