Provider Demographics
NPI:1992845903
Name:ROSA, WILMA AGOSTO (RPH)
Entity Type:Individual
Prefix:MRS
First Name:WILMA
Middle Name:AGOSTO
Last Name:ROSA
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:WILMA
Other - Middle Name:AGOSTO
Other - Last Name:ROSA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RPH
Mailing Address - Street 1:PO BOX 20122
Mailing Address - Street 2:SAN JUAN
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00928-0122
Mailing Address - Country:US
Mailing Address - Phone:787-757-6762
Mailing Address - Fax:
Practice Address - Street 1:86 GERGTI RIO PIEDRAS
Practice Address - Street 2:SAN JUAN
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00928-0122
Practice Address - Country:US
Practice Address - Phone:787-757-6762
Practice Address - Fax:787-772-9221
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR2287183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR2287OtherLIC DE PR