Provider Demographics
NPI:1679809651
Name:PORTAL, JESUS GUILLERMO (RPH)
Entity Type:Individual
Prefix:MR
First Name:JESUS
Middle Name:GUILLERMO
Last Name:PORTAL
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:67 MENDEZ VIGO E
Mailing Address - Street 2:
Mailing Address - City:MAYAGUEZ
Mailing Address - State:PR
Mailing Address - Zip Code:00680-4934
Mailing Address - Country:US
Mailing Address - Phone:787-832-6645
Mailing Address - Fax:
Practice Address - Street 1:67 MENDEZ VIGO E
Practice Address - Street 2:
Practice Address - City:MAYAGUEZ
Practice Address - State:PR
Practice Address - Zip Code:00680-4934
Practice Address - Country:US
Practice Address - Phone:787-832-6645
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-10-26
Last Update Date:2009-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR4335183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR4335OtherPHARMACIST STATE LICENSE