Provider Demographics
NPI:1205037264
Name:JUSINO, PROVIDENCIA
Entity Type:Individual
Prefix:
First Name:PROVIDENCIA
Middle Name:
Last Name:JUSINO
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:CARR 830 KM 4.1 CERRO GORDO
Mailing Address - Street 2:
Mailing Address - City:BYAMON
Mailing Address - State:PR
Mailing Address - Zip Code:00956
Mailing Address - Country:US
Mailing Address - Phone:787-279-5310
Mailing Address - Fax:
Practice Address - Street 1:URB SANTA CRUZ # 70 CALLE SANTA CRUZ
Practice Address - Street 2:
Practice Address - City:BAYAMON
Practice Address - State:PR
Practice Address - Zip Code:00960
Practice Address - Country:US
Practice Address - Phone:787-740-4747
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR2127183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician