Provider Demographics
NPI:1104241645
Name:FUGOSO, TERESITA
Entity type:Individual
Prefix:
First Name:TERESITA
Middle Name:
Last Name:FUGOSO
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 1:2302 BROWN RD
Mailing Address - Street 2:CENTINELA STATE PRISON PHARMACY
Mailing Address - City:IMPERIAL
Mailing Address - State:CA
Mailing Address - Zip Code:92251
Mailing Address - Country:US
Mailing Address - Phone:760-337-7624
Mailing Address - Fax:760-482-3006
Practice Address - Street 1:2302 BROWN RD
Practice Address - Street 2:CENTINELA STATE PRISON PHARMACY
Practice Address - City:IMPERIAL
Practice Address - State:CA
Practice Address - Zip Code:92251
Practice Address - Country:US
Practice Address - Phone:760-337-7624
Practice Address - Fax:760-482-3006
Is Sole Proprietor?:No
Enumeration Date:2014-02-20
Last Update Date:2014-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARPH183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist