Provider Demographics
NPI:1548578081
Name:MEDINA, MIRIAM (RPH)
Entity Type:Individual
Prefix:MRS
First Name:MIRIAM
Middle Name:
Last Name:MEDINA
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:628 KENWICK CIR
Mailing Address - Street 2:APT. 205
Mailing Address - City:CASSELBERRY
Mailing Address - State:FL
Mailing Address - Zip Code:32707-7006
Mailing Address - Country:US
Mailing Address - Phone:407-260-1544
Mailing Address - Fax:
Practice Address - Street 1:7800 US HIGHWAY 17/92
Practice Address - Street 2:
Practice Address - City:FERN PARK
Practice Address - State:FL
Practice Address - Zip Code:32730-2243
Practice Address - Country:US
Practice Address - Phone:407-339-5661
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-17
Last Update Date:2010-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS44131183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist