Provider Demographics
NPI:1780917971
Name:LUCERO, MIRIAM (PHARMD)
Entity type:Individual
Prefix:
First Name:MIRIAM
Middle Name:
Last Name:LUCERO
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 1:3401 ISLETA BLVD SW
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87105-5836
Mailing Address - Country:US
Mailing Address - Phone:505-877-3130
Mailing Address - Fax:505-877-8072
Practice Address - Street 1:1625 RIO BRAVO BLVD SW
Practice Address - Street 2:SUITE 36
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87105-6057
Practice Address - Country:US
Practice Address - Phone:505-877-3130
Practice Address - Fax:505-877-8072
Is Sole Proprietor?:No
Enumeration Date:2009-09-07
Last Update Date:2017-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMRP00006451183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist