Individual
BRADEN JACOB WALLACE
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
PHARMD
Contact information
Practice address
1700 CERRILLOS RD, SANTA FE, NM 87505-3026
(505) 946-9387
Mailing address
3600 CERRILLOS RD STE 732, SANTA FE, NM 87507-2689
(918) 989-6276
Taxonomy
Speciality
Code
Description
License number
State
183500000X
Pharmacist
Primary
0022441
CO
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
PHA.0022441
PHARMACIST LICENSE NUMBER
CO
Enumeration date
11/21/2018
Last updated
11/21/2018
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