Provider Demographics
NPI:1568724177
Name:JIMENEZ, GUSTAVO (PHARM D)
Entity Type:Individual
Prefix:DR
First Name:GUSTAVO
Middle Name:
Last Name:JIMENEZ
Suffix:
Gender:M
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:153 CALLE GARDENIA
Mailing Address - Street 2:ROUND HILL
Mailing Address - City:TRUJILLO ALTO
Mailing Address - State:PR
Mailing Address - Zip Code:00976-2703
Mailing Address - Country:US
Mailing Address - Phone:787-677-6368
Mailing Address - Fax:
Practice Address - Street 1:ENCANTADA PLZ # 181
Practice Address - Street 2:
Practice Address - City:TRUJILLO ALTO
Practice Address - State:PR
Practice Address - Zip Code:00976-6301
Practice Address - Country:US
Practice Address - Phone:787-292-2050
Practice Address - Fax:787-755-6836
Is Sole Proprietor?:No
Enumeration Date:2012-06-10
Last Update Date:2012-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR55611835P1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P1200XPharmacy Service ProvidersPharmacistPharmacotherapy