Provider Demographics
NPI:1649499567
Name:BREEDEN, CHARLOTTE SOPHIA (RPH)
Entity type:Individual
Prefix:
First Name:CHARLOTTE
Middle Name:SOPHIA
Last Name:BREEDEN
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5124 ROANOKE AVE NW
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87120-4541
Mailing Address - Country:US
Mailing Address - Phone:505-239-1612
Mailing Address - Fax:
Practice Address - Street 1:3301 LOS ARBOLES AVE NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87107-1943
Practice Address - Country:US
Practice Address - Phone:505-800-7092
Practice Address - Fax:505-888-2851
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-25
Last Update Date:2016-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM5392183500000X, 1835G0303X, 1835P1200X, 1835P1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
No1835G0303XPharmacy Service ProvidersPharmacistGeriatric
No1835P1200XPharmacy Service ProvidersPharmacistPharmacotherapy
No1835P1300XPharmacy Service ProvidersPharmacistPsychiatric
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM37101056Medicaid