Provider Demographics
NPI:1124303201
Name:CAMPUSANO, GREGORINA ALTAGRACIA
Entity type:Individual
Prefix:
First Name:GREGORINA
Middle Name:ALTAGRACIA
Last Name:CAMPUSANO
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 1:2931 11TH ST NW
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20001-3903
Mailing Address - Country:US
Mailing Address - Phone:202-714-4488
Mailing Address - Fax:
Practice Address - Street 1:3524 CONNECTICUT AVE NW
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20008-2401
Practice Address - Country:US
Practice Address - Phone:202-686-6927
Practice Address - Fax:202-686-3870
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-20
Last Update Date:2011-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCPH100000807183500000X
MD17085183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist