Provider Demographics
NPI:1003380486
Name:JIMENEZ, GLORIMAR
Entity Type:Individual
Prefix:
First Name:GLORIMAR
Middle Name:
Last Name:JIMENEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:HC 1 BOX 5810
Mailing Address - Street 2:
Mailing Address - City:SABANA HOYOS
Mailing Address - State:PR
Mailing Address - Zip Code:00688-8655
Mailing Address - Country:US
Mailing Address - Phone:787-881-2440
Mailing Address - Fax:
Practice Address - Street 1:CARR 2 KM 62.7 SABANA HOYOS
Practice Address - Street 2:
Practice Address - City:ARECIBO
Practice Address - State:PR
Practice Address - Zip Code:00612
Practice Address - Country:US
Practice Address - Phone:787-881-2440
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-18
Last Update Date:2019-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR11209183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183700000XPharmacy Service ProvidersPharmacy TechnicianGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR4843297OtherDRIVER LICENCE