Provider Demographics
NPI:1922685346
Name:MORENO, MIGUEL
Entity Type:Individual
Prefix:
First Name:MIGUEL
Middle Name:
Last Name:MORENO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15518 NW 77TH CT
Mailing Address - Street 2:
Mailing Address - City:MIAMI LAKES
Mailing Address - State:FL
Mailing Address - Zip Code:33016-5804
Mailing Address - Country:US
Mailing Address - Phone:305-823-3461
Mailing Address - Fax:305-557-6945
Practice Address - Street 1:15518 NW 77TH CT
Practice Address - Street 2:
Practice Address - City:MIAMI LAKES
Practice Address - State:FL
Practice Address - Zip Code:33016-5804
Practice Address - Country:US
Practice Address - Phone:305-823-3461
Practice Address - Fax:305-557-6945
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-24
Last Update Date:2021-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS21802183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist