Provider Demographics
NPI:1083083232
Name:MONTALVO, GLORIA
Entity Type:Individual
Prefix:
First Name:GLORIA
Middle Name:
Last Name:MONTALVO
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:PO BOX 754
Mailing Address - Street 2:
Mailing Address - City:CABO ROJO
Mailing Address - State:PR
Mailing Address - Zip Code:00623-0754
Mailing Address - Country:US
Mailing Address - Phone:787-458-8103
Mailing Address - Fax:
Practice Address - Street 1:CARR 102 AVE PEDRO ALBIZU CAMPOS
Practice Address - Street 2:CENTRO PROFESIONAL BORINQUEN
Practice Address - City:CABO ROJO
Practice Address - State:PR
Practice Address - Zip Code:00623-0754
Practice Address - Country:US
Practice Address - Phone:787-458-8103
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-09-17
Last Update Date:2015-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR3255183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist