Provider Demographics
NPI:1447434618
Name:AUTREY, LORI ALISON (RPH)
Entity type:Individual
Prefix:MRS
First Name:LORI
Middle Name:ALISON
Last Name:AUTREY
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:PO BOX 969
Mailing Address - Street 2:111 W, BROADWAY
Mailing Address - City:MOUNTAINAIR
Mailing Address - State:NM
Mailing Address - Zip Code:87036-0969
Mailing Address - Country:US
Mailing Address - Phone:505-847-0242
Mailing Address - Fax:505-847-0252
Practice Address - Street 1:111 WEST BROADWAY
Practice Address - Street 2:
Practice Address - City:MOUNTAINAIR
Practice Address - State:NM
Practice Address - Zip Code:87036
Practice Address - Country:US
Practice Address - Phone:505-847-0242
Practice Address - Fax:505-847-0252
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-24
Last Update Date:2007-12-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMRPH00006163183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist