Provider Demographics
NPI:1831485663
Name:BAUTISTA, GIRLIE
Entity Type:Individual
Prefix:
First Name:GIRLIE
Middle Name:
Last Name:BAUTISTA
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 1:10478 N NC HIGHWAY 109
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27107-9634
Mailing Address - Country:US
Mailing Address - Phone:336-769-0872
Mailing Address - Fax:
Practice Address - Street 1:10478 N NC HIGHWAY 109
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27107-9634
Practice Address - Country:US
Practice Address - Phone:336-769-0872
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-20
Last Update Date:2011-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC18687183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist