Provider Demographics
NPI:1497056030
Name:DELLUPAC, MYLA AGUSTIN
Entity Type:Individual
Prefix:
First Name:MYLA
Middle Name:AGUSTIN
Last Name:DELLUPAC
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 1:12251 DARNESTOWN RD
Mailing Address - Street 2:
Mailing Address - City:GAITHERSBURG
Mailing Address - State:MD
Mailing Address - Zip Code:20878-2203
Mailing Address - Country:US
Mailing Address - Phone:301-417-0922
Mailing Address - Fax:
Practice Address - Street 1:12251 DARNESTOWN RD
Practice Address - Street 2:
Practice Address - City:GAITHERSBURG
Practice Address - State:MD
Practice Address - Zip Code:20878-2203
Practice Address - Country:US
Practice Address - Phone:301-417-0922
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-11-13
Last Update Date:2010-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD18622183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist