Provider Demographics
NPI:1417235722
Name:GONGORA, MIRIAM
Entity Type:Individual
Prefix:MS
First Name:MIRIAM
Middle Name:
Last Name:GONGORA
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 1:1990 W 56TH ST APT 1203
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33012-6918
Mailing Address - Country:US
Mailing Address - Phone:786-380-6108
Mailing Address - Fax:
Practice Address - Street 1:1990 W 56 ST
Practice Address - Street 2:APT 1203
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33012
Practice Address - Country:US
Practice Address - Phone:786-380-6108
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-08-03
Last Update Date:2011-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRPT29627183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician