Provider Demographics
NPI:1871027953
Name:TRINIDAD, GLORIA IVELISSE
Entity Type:Individual
Prefix:
First Name:GLORIA
Middle Name:IVELISSE
Last Name:TRINIDAD
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 1:323 CALLE 4
Mailing Address - Street 2:URB VILLA PAZ
Mailing Address - City:TRUJILLO ALTO
Mailing Address - State:PR
Mailing Address - Zip Code:00976
Mailing Address - Country:US
Mailing Address - Phone:787-283-3545
Mailing Address - Fax:787-761-4557
Practice Address - Street 1:NORTHWEST CORNER OF PR 181 AND PR 850
Practice Address - Street 2:
Practice Address - City:TRUJILLO ALTO
Practice Address - State:PR
Practice Address - Zip Code:00976
Practice Address - Country:US
Practice Address - Phone:787-283-3545
Practice Address - Fax:787-761-4557
Is Sole Proprietor?:No
Enumeration Date:2017-04-17
Last Update Date:2017-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR6472183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist