Provider Demographics
NPI:1740329457
Name:MIRANDA, ILIANETTE (RPH)
Entity type:Individual
Prefix:MRS
First Name:ILIANETTE
Middle Name:
Last Name:MIRANDA
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:139 CALLE PEDRO D ACOSTA
Mailing Address - Street 2:URB. SANTA MARIA
Mailing Address - City:SABANA GRANDE
Mailing Address - State:PR
Mailing Address - Zip Code:00637-2079
Mailing Address - Country:US
Mailing Address - Phone:178-784-9074
Mailing Address - Fax:178-784-9301
Practice Address - Street 1:CARR. #2 KM 1.64
Practice Address - Street 2:PLAZA MONSERRATE
Practice Address - City:HORMIGUEROS
Practice Address - State:PR
Practice Address - Zip Code:00660
Practice Address - Country:US
Practice Address - Phone:178-784-9074
Practice Address - Fax:178-784-9301
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR4878183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist