Provider Demographics
NPI:1386931368
Name:DE JESUS, CARMEN MILAGROS
Entity type:Individual
Prefix:
First Name:CARMEN
Middle Name:MILAGROS
Last Name:DE JESUS
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:CENTRO MERCADO PLAZA CARR 152 KM 16.0
Mailing Address - Street 2:
Mailing Address - City:NARANJITO
Mailing Address - State:PR
Mailing Address - Zip Code:00719-3809
Mailing Address - Country:US
Mailing Address - Phone:787-869-0240
Mailing Address - Fax:
Practice Address - Street 1:CENTRO MERCADO PLAZA CARR 152 KM 16.0
Practice Address - Street 2:
Practice Address - City:NARANJITO
Practice Address - State:PR
Practice Address - Zip Code:00719
Practice Address - Country:US
Practice Address - Phone:787-869-0240
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-06-29
Last Update Date:2011-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR5122183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist