Provider Demographics
NPI:1154793693
Name:BURGOS, JOHANNA I (RPH)
Entity type:Individual
Prefix:MRS
First Name:JOHANNA
Middle Name:I
Last Name:BURGOS
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:6 CALLE 1
Mailing Address - Street 2:URB. TOMAS C MADURO
Mailing Address - City:JUANA DIAZ
Mailing Address - State:PR
Mailing Address - Zip Code:00795-0000
Mailing Address - Country:US
Mailing Address - Phone:787-644-1466
Mailing Address - Fax:847-396-2784
Practice Address - Street 1:CARR 149 & 584
Practice Address - Street 2:PLAZA JUANA DIAZ
Practice Address - City:JUANA DIAZ
Practice Address - State:PR
Practice Address - Zip Code:00795-0000
Practice Address - Country:US
Practice Address - Phone:787-260-0530
Practice Address - Fax:847-396-2784
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-23
Last Update Date:2015-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR004890183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist