Provider Demographics
NPI:1972827657
Name:GUTIERREZ, MIREYA (/RPH)
Entity Type:Individual
Prefix:MRS
First Name:MIREYA
Middle Name:
Last Name:GUTIERREZ
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 1:9020 ELMHURST AVE
Mailing Address - Street 2:
Mailing Address - City:JACKSON HEIGHTS
Mailing Address - State:NY
Mailing Address - Zip Code:11372-7936
Mailing Address - Country:US
Mailing Address - Phone:718-651-1177
Mailing Address - Fax:718-651-5732
Practice Address - Street 1:9020 ELMHURST AVE
Practice Address - Street 2:
Practice Address - City:JACKSON HEIGHTS
Practice Address - State:NY
Practice Address - Zip Code:11372-7936
Practice Address - Country:US
Practice Address - Phone:718-651-1177
Practice Address - Fax:718-651-5732
Is Sole Proprietor?:No
Enumeration Date:2010-03-24
Last Update Date:2010-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY36079183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY020865Medicaid
NY020865Medicaid