Provider Demographics
NPI:1578100954
Name:CORALES, GLENDA LIZZETTE
Entity Type:Individual
Prefix:MRS
First Name:GLENDA
Middle Name:LIZZETTE
Last Name:CORALES
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:URB. FLAMBOYAN GDNS
Mailing Address - Street 2:600 CALLE MARGINAL
Mailing Address - City:BAYAMON
Mailing Address - State:PR
Mailing Address - Zip Code:00959-5857
Mailing Address - Country:US
Mailing Address - Phone:787-784-0411
Mailing Address - Fax:787-784-0488
Practice Address - Street 1:167 AND NUMBER 2 STREET
Practice Address - Street 2:
Practice Address - City:BAYAMON
Practice Address - State:PR
Practice Address - Zip Code:00956
Practice Address - Country:US
Practice Address - Phone:787-785-0411
Practice Address - Fax:787-785-0488
Is Sole Proprietor?:No
Enumeration Date:2019-12-05
Last Update Date:2019-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR3962183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist