Provider Demographics
NPI:1922151125
Name:GUTMAN, MIRALDA
Entity Type:Individual
Prefix:MRS
First Name:MIRALDA
Middle Name:
Last Name:GUTMAN
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 1:320 MARION AVE
Mailing Address - Street 2:
Mailing Address - City:PLANTSVILLE
Mailing Address - State:CT
Mailing Address - Zip Code:06479-1407
Mailing Address - Country:US
Mailing Address - Phone:860-628-0899
Mailing Address - Fax:203-235-0244
Practice Address - Street 1:172 W MAIN ST
Practice Address - Street 2:
Practice Address - City:MERIDEN
Practice Address - State:CT
Practice Address - Zip Code:06451-4104
Practice Address - Country:US
Practice Address - Phone:203-235-6305
Practice Address - Fax:203-235-0244
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT2916183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT2916OtherPHARM TEC