Provider Demographics
NPI:1619424538
Name:MIRANDA, LUIS ANGEL (CPHT)
Entity Type:Individual
Prefix:
First Name:LUIS
Middle Name:ANGEL
Last Name:MIRANDA
Suffix:
Gender:M
Credentials:CPHT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:F2 CALLE EDINBURGO
Mailing Address - Street 2:
Mailing Address - City:CAGUAS
Mailing Address - State:PR
Mailing Address - Zip Code:00725-6232
Mailing Address - Country:US
Mailing Address - Phone:787-560-0029
Mailing Address - Fax:
Practice Address - Street 1:Q48 AVE LUIS MUNOZ MARIN
Practice Address - Street 2:
Practice Address - City:CAGUAS
Practice Address - State:PR
Practice Address - Zip Code:00725-6158
Practice Address - Country:US
Practice Address - Phone:787-743-3365
Practice Address - Fax:787-744-6889
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-08
Last Update Date:2016-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR11254183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician