Provider Demographics
NPI:1689941742
Name:GUTIERREZ, NYDIA MILAGROS (RPH)
Entity Type:Individual
Prefix:
First Name:NYDIA
Middle Name:MILAGROS
Last Name:GUTIERREZ
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:140 FOSTER TRACE DR
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30043-6523
Mailing Address - Country:US
Mailing Address - Phone:770-513-7427
Mailing Address - Fax:678-482-9220
Practice Address - Street 1:1605 BUFORD HWY
Practice Address - Street 2:
Practice Address - City:BUFORD
Practice Address - State:GA
Practice Address - Zip Code:30518-3632
Practice Address - Country:US
Practice Address - Phone:770-945-0507
Practice Address - Fax:678-482-9220
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-17
Last Update Date:2011-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA019019183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA019019OtherSTATE PHARMACY LIC