Provider Demographics
NPI:1720639156
Name:PEREZ, GLENDA
Entity Type:Individual
Prefix:
First Name:GLENDA
Middle Name:
Last Name:PEREZ
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 1:40 NW 87TH AVE APT D210
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33172-4527
Mailing Address - Country:US
Mailing Address - Phone:786-413-7459
Mailing Address - Fax:
Practice Address - Street 1:1601 SW 107TH AVE
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33165-7344
Practice Address - Country:US
Practice Address - Phone:305-554-1706
Practice Address - Fax:305-554-1706
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-26
Last Update Date:2019-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS59284183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist