Provider Demographics
NPI:1023523248
Name:DUTRO, MICHAEL P (PHARMD, RPH)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:P
Last Name:DUTRO
Suffix:
Gender:M
Credentials:PHARMD, RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5812 VALERIAN PL NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87111-8121
Mailing Address - Country:US
Mailing Address - Phone:505-292-8103
Mailing Address - Fax:
Practice Address - Street 1:5812 VALERIAN PL NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87111-8121
Practice Address - Country:US
Practice Address - Phone:505-292-8103
Practice Address - Fax:505-292-8103
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-11
Last Update Date:2017-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM5089183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist