Provider Demographics
NPI:1710594866
Name:DE JESUS, MIRTHA ROSA
Entity Type:Individual
Prefix:
First Name:MIRTHA
Middle Name:ROSA
Last Name:DE JESUS
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 1:2353 OCOEE APOPKA RD
Mailing Address - Street 2:
Mailing Address - City:OCOEE
Mailing Address - State:FL
Mailing Address - Zip Code:34761-5301
Mailing Address - Country:US
Mailing Address - Phone:407-573-0228
Mailing Address - Fax:
Practice Address - Street 1:2353 OCOEE APOPKA RD
Practice Address - Street 2:
Practice Address - City:OCOEE
Practice Address - State:FL
Practice Address - Zip Code:34761-5301
Practice Address - Country:US
Practice Address - Phone:407-573-0228
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-23
Last Update Date:2020-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRPT66870183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician