Provider Demographics
NPI:1669765400
Name:MEDINA, MILDRED (PHARMACIST)
Entity type:Individual
Prefix:
First Name:MILDRED
Middle Name:
Last Name:MEDINA
Suffix:
Gender:F
Credentials:PHARMACIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4203 CALLE MARGINAL
Mailing Address - Street 2:
Mailing Address - City:FAJARDO
Mailing Address - State:PR
Mailing Address - Zip Code:00738-3652
Mailing Address - Country:US
Mailing Address - Phone:787-860-1600
Mailing Address - Fax:787-860-1614
Practice Address - Street 1:4203 CALLE MARGINAL
Practice Address - Street 2:
Practice Address - City:FAJARDO
Practice Address - State:PR
Practice Address - Zip Code:00738-3652
Practice Address - Country:US
Practice Address - Phone:787-860-1600
Practice Address - Fax:787-860-1614
Is Sole Proprietor?:No
Enumeration Date:2011-05-26
Last Update Date:2011-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR4645183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist