Provider Demographics
NPI:1609480326
Name:BAUTA ALFONSO, LAURA
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:BAUTA ALFONSO
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 1:1155 W 68TH ST
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33014-5152
Mailing Address - Country:US
Mailing Address - Phone:305-362-0978
Mailing Address - Fax:
Practice Address - Street 1:1155 W 68TH ST
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33014-5152
Practice Address - Country:US
Practice Address - Phone:305-362-0978
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-01
Last Update Date:2020-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS61475183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist