Provider Demographics
NPI:1568732881
Name:BUSTELO, JOAN M
Entity Type:Individual
Prefix:
First Name:JOAN
Middle Name:M
Last Name:BUSTELO
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 1:8250 NW 27TH ST STE 311
Mailing Address - Street 2:
Mailing Address - City:DORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33122-1904
Mailing Address - Country:US
Mailing Address - Phone:305-591-1085
Mailing Address - Fax:305-591-7402
Practice Address - Street 1:8250 NW 27TH ST STE 311
Practice Address - Street 2:
Practice Address - City:DORAL
Practice Address - State:FL
Practice Address - Zip Code:33122-1904
Practice Address - Country:US
Practice Address - Phone:305-591-1085
Practice Address - Fax:305-591-7402
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-03
Last Update Date:2012-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL24496183500000X
PR4509183500000X
IL051.294591183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist