Provider Demographics
NPI:1336368695
Name:DOMINGUEZ, WANDA I
Entity Type:Individual
Prefix:MISS
First Name:WANDA
Middle Name:I
Last Name:DOMINGUEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:URB. VALLE DEL TESORO #41 CALLE TURQUESA
Mailing Address - Street 2:
Mailing Address - City:GURABO
Mailing Address - State:PR
Mailing Address - Zip Code:00778
Mailing Address - Country:US
Mailing Address - Phone:787-313-0311
Mailing Address - Fax:787-734-3180
Practice Address - Street 1:35 CALLE MUNOZ RIVERA
Practice Address - Street 2:
Practice Address - City:JUNCOS
Practice Address - State:PR
Practice Address - Zip Code:00777-3114
Practice Address - Country:US
Practice Address - Phone:787-734-3055
Practice Address - Fax:787-734-3180
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR1301183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician