Provider Demographics
NPI:1285239145
Name:FRAGOSO, PABLO (RPH)
Entity type:Individual
Prefix:MR
First Name:PABLO
Middle Name:
Last Name:FRAGOSO
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:540 STEVENS AVE
Mailing Address - Street 2:
Mailing Address - City:RIDGEWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:07450-5438
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:18 W BLACKWELL ST
Practice Address - Street 2:
Practice Address - City:DOVER
Practice Address - State:NJ
Practice Address - Zip Code:07801-3841
Practice Address - Country:US
Practice Address - Phone:973-328-3344
Practice Address - Fax:973-328-6817
Is Sole Proprietor?:No
Enumeration Date:2020-11-30
Last Update Date:2022-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ28RI2015800183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist