Provider Demographics
NPI:1558686881
Name:JUAREZ, CONSUELO
Entity Type:Individual
Prefix:
First Name:CONSUELO
Middle Name:
Last Name:JUAREZ
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 1:21819 93RD AVE
Mailing Address - Street 2:
Mailing Address - City:QUEENS VILLAGE
Mailing Address - State:NY
Mailing Address - Zip Code:11428-1838
Mailing Address - Country:US
Mailing Address - Phone:718-479-6615
Mailing Address - Fax:
Practice Address - Street 1:291 KNICKERBOCKER AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11237-3103
Practice Address - Country:US
Practice Address - Phone:718-456-5475
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-03-30
Last Update Date:2010-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY033787183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist