Provider Demographics
NPI:1457830424
Name:SMITH, ANGEL LADEANE (PHARM D)
Entity Type:Individual
Prefix:
First Name:ANGEL
Middle Name:LADEANE
Last Name:SMITH
Suffix:
Gender:F
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1035 AVENUE C
Mailing Address - Street 2:
Mailing Address - City:ELY
Mailing Address - State:NV
Mailing Address - Zip Code:89301-2329
Mailing Address - Country:US
Mailing Address - Phone:307-680-5483
Mailing Address - Fax:
Practice Address - Street 1:1035 AVENUE C
Practice Address - Street 2:
Practice Address - City:ELY
Practice Address - State:NV
Practice Address - Zip Code:89301-2329
Practice Address - Country:US
Practice Address - Phone:307-680-5483
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-10
Last Update Date:2018-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT5243183500000X
NV18946183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV18946OtherSTATE BOARD OF PHARMACY
MT5243OtherSTATE BOARD OF PHARMACY