Provider Demographics
NPI:1699073833
Name:JURADO, BRIGIDA MIMOSA
Entity type:Individual
Prefix:MRS
First Name:BRIGIDA
Middle Name:MIMOSA
Last Name:JURADO
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 1:4535 PEBBLE LAKE DR
Mailing Address - Street 2:
Mailing Address - City:PFAFFTOWN
Mailing Address - State:NC
Mailing Address - Zip Code:27040-9241
Mailing Address - Country:US
Mailing Address - Phone:336-414-2640
Mailing Address - Fax:
Practice Address - Street 1:6798 SHALLOWFORD RD
Practice Address - Street 2:
Practice Address - City:LEWISVILLE
Practice Address - State:NC
Practice Address - Zip Code:27023-9724
Practice Address - Country:US
Practice Address - Phone:336-945-2106
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-12
Last Update Date:2011-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC18550183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist