Provider Demographics
NPI:1104164722
Name:ESTEFAN, MARIAM
Entity type:Individual
Prefix:
First Name:MARIAM
Middle Name:
Last Name:ESTEFAN
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 1:16825 E COLONIAL DR
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32820-1910
Mailing Address - Country:US
Mailing Address - Phone:407-568-1631
Mailing Address - Fax:
Practice Address - Street 1:16825 E COLONIAL DR
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32820-1910
Practice Address - Country:US
Practice Address - Phone:407-568-1631
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-01-17
Last Update Date:2013-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS50040183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist