Provider Demographics
NPI:1699385104
Name:MAYBERRY, DUSTIN (PHARMD)
Entity Type:Individual
Prefix:
First Name:DUSTIN
Middle Name:
Last Name:MAYBERRY
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 1:4404 BARRETT AVE NW
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87114-6529
Mailing Address - Country:US
Mailing Address - Phone:575-956-5114
Mailing Address - Fax:
Practice Address - Street 1:4404 BARRETT AVE NW
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87114-6529
Practice Address - Country:US
Practice Address - Phone:575-956-5114
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-10
Last Update Date:2020-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMRP00009299183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMRP00009299OtherNMBOP