Provider Demographics
NPI:1922218312
Name:BURGOS, GRACE A (RPH)
Entity Type:Individual
Prefix:
First Name:GRACE
Middle Name:A
Last Name:BURGOS
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:137 CALLE BEGONIA
Mailing Address - Street 2:CIUDAD JARDIN II
Mailing Address - City:TOA ALTA
Mailing Address - State:PR
Mailing Address - Zip Code:00953-4853
Mailing Address - Country:US
Mailing Address - Phone:787-781-4585
Mailing Address - Fax:787-783-2951
Practice Address - Street 1:137 CALLE BEGONIA
Practice Address - Street 2:CIUDAD JARDIN II
Practice Address - City:TOA ALTA
Practice Address - State:PR
Practice Address - Zip Code:00953
Practice Address - Country:US
Practice Address - Phone:787-781-4585
Practice Address - Fax:787-783-2951
Is Sole Proprietor?:No
Enumeration Date:2007-05-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR3855183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR3855OtherSTATE LICENCE