Provider Demographics
NPI:1801933882
Name:WADE, KATHLEEN T (RPH, PHARM D, PHC)
Entity type:Individual
Prefix:DR
First Name:KATHLEEN
Middle Name:T
Last Name:WADE
Suffix:
Gender:F
Credentials:RPH, PHARM D, PHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 206
Mailing Address - Street 2:
Mailing Address - City:CEDAR CREST
Mailing Address - State:NM
Mailing Address - Zip Code:87008-0206
Mailing Address - Country:US
Mailing Address - Phone:505-281-5720
Mailing Address - Fax:
Practice Address - Street 1:8300 CONSTITUTION PL NE RM 1132
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87110-7637
Practice Address - Country:US
Practice Address - Phone:505-291-2402
Practice Address - Fax:505-291-2546
Is Sole Proprietor?:No
Enumeration Date:2007-01-31
Last Update Date:2008-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMRP00004892183500000X
NM48921835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
No183500000XPharmacy Service ProvidersPharmacist