Provider Demographics
NPI:1730657263
Name:ESPINOZA, MELISSA AUXILIADORA
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:AUXILIADORA
Last Name:ESPINOZA
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 1:2020 N 61ST AVE
Mailing Address - Street 2:
Mailing Address - City:HOLLYWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:33024-4204
Mailing Address - Country:US
Mailing Address - Phone:954-632-6192
Mailing Address - Fax:
Practice Address - Street 1:1700 SHERIDAN ST
Practice Address - Street 2:
Practice Address - City:HOLLYWOOD
Practice Address - State:FL
Practice Address - Zip Code:33020-2275
Practice Address - Country:US
Practice Address - Phone:954-926-6657
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-02
Last Update Date:2018-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS58431183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL10910770Medicaid